1
|
Lobato CB, Winding CT, Bojsen-Møller KN, Martinussen C, Veedfald S, Holst JJ, Madsbad S, Jørgensen NB, Dirksen C. Canagliflozin or acarbose versus placebo to ameliorate post-bariatric hypoglycaemia - The HypoBar I randomized clinical trial protocol. Diabet Med 2024; 41:e15320. [PMID: 38551152 DOI: 10.1111/dme.15320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 03/11/2024] [Accepted: 03/12/2024] [Indexed: 05/12/2024]
Abstract
INTRODUCTION Post-bariatric hypoglycaemia (PBH) is a rare yet disabling clinical condition, mostly reported after Roux-en-Y gastric bypass (RYGB) surgery. RYGB is one of the most widely used and effective bariatric procedures. The pathophysiology of PBH remains unclear, and treatment options are limited in effectiveness and/or carry significant side effects. Acarbose slows carbohydrates digestion and absorption and is generally considered first-line pharmacological treatment for PBH but its gastrointestinal side effects limit patient compliance. Canagliflozin inhibits intestinal and renal sodium-dependent glucose absorption and reduces postprandial excursions of glucose, insulin and incretins after RYGB - effects that could be beneficial in ameliorating PBH. AIMS The trial aims to investigate how blood glucose levels are affected during daily living in subjects with PBH during treatment with canagliflozin or acarbose compared with placebo, and to study the meal-induced entero-endocrine mechanisms implied in the treatment responses. METHODS In a double-blinded, randomized, crossover clinical trial, HypoBar I will investigate the effectiveness in reducing the risk of PBH, safety, ambulatory glucose profile and entero-endocrine responses when PBH is treated with canagliflozin 300 mg twice daily during a 4-week intervention period, compared with acarbose 50 mg thrice daily or placebo. ETHICS AND DISSEMINATION HypoBar I is approved by the Local regulatory entities. Results will be published in peer-reviewed journals. CONCLUSION If effective, well-tolerated and safe, canagliflozin could be a novel treatment for people with PBH. HypoBar I might also unravel new mechanisms underlying PBH, potentially identifying new treatment targets. TRIAL REGISTRATION EudraCT number 2022-000157-87.
Collapse
Affiliation(s)
- Carolina B Lobato
- Department of Medicine, Copenhagen University Hospital, Amager and Hvidovre, Section of Endocrinology, Hvidovre, Denmark
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Clara Tornoe Winding
- Department of Medicine, Copenhagen University Hospital, Amager and Hvidovre, Section of Endocrinology, Hvidovre, Denmark
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Kirstine N Bojsen-Møller
- Department of Medicine, Copenhagen University Hospital, Amager and Hvidovre, Section of Endocrinology, Hvidovre, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Christoffer Martinussen
- Department of Medicine, Copenhagen University Hospital, Amager and Hvidovre, Section of Endocrinology, Hvidovre, Denmark
| | - Simon Veedfald
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jens J Holst
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Novo Nordisk Foundation Centre for Basic Metabolic Research, Copenhagen, Denmark
| | - Sten Madsbad
- Department of Medicine, Copenhagen University Hospital, Amager and Hvidovre, Section of Endocrinology, Hvidovre, Denmark
| | - Nils Bruun Jørgensen
- Department of Medicine, Copenhagen University Hospital, Amager and Hvidovre, Section of Endocrinology, Hvidovre, Denmark
| | - Carsten Dirksen
- Department of Medicine, Copenhagen University Hospital, Amager and Hvidovre, Section of Endocrinology, Hvidovre, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
2
|
Lundqvist MH, Pereira MJ, Almby K, Hetty S, Eriksson JW. Regulation of the Cortisol Axis, Glucagon, and Growth Hormone by Glucose Is Altered in Prediabetes and Type 2 Diabetes. J Clin Endocrinol Metab 2024; 109:e675-e688. [PMID: 37708362 PMCID: PMC10795937 DOI: 10.1210/clinem/dgad549] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 08/17/2023] [Accepted: 09/12/2023] [Indexed: 09/16/2023]
Abstract
CONTEXT Insulin-antagonistic, counter-regulatory hormones have been implicated in the development of type 2 diabetes (T2D). OBJECTIVE In this cross-sectional study, we investigated whether glucose-dependent regulation of such hormones differ in individuals with T2D, prediabetes (PD), and normoglycemia (NG). METHODS Fifty-four individuals with or without T2D underwent one hyperinsulinemic-normoglycemic-hypoglycemic and one hyperglycemic clamp with repeated hormonal measurements. Participants with T2D (n = 19) were compared with a group-matched (age, sex, BMI) subset of participants without diabetes (ND, n = 17), and also with participants with PD (n = 18) and NG (n = 17). RESULTS In T2D vs ND, glucagon levels were higher and less suppressed during the hyperglycemic clamp whereas growth hormone (GH) levels were lower during hypoglycemia (P < .05). Augmented ACTH response to hypoglycemia was present in PD vs NG (P < .05), with no further elevation in T2D. In contrast, glucagon and GH alterations were more marked in T2D vs PD (P < .05).In the full cohort (n = 54), augmented responses of glucagon, cortisol, and ACTH and attenuated responses of GH correlated with adiposity, dysglycemia, and insulin resistance. In multilinear regressions, insulin resistance was the strongest predictor of elevated hypoglycemic responses of glucagon, cortisol, and ACTH. Conversely, fasting glucose and HbA1c were the strongest predictors of low GH levels during hypoglycemia and elevated, i.e. less suppressed glucagon levels during hyperglycemia, respectively. Notably, adiposity measures were also strongly associated with the responses above. CONCLUSIONS Altered counter-regulatory hormonal responses to glucose variations are observed at different stages of T2D development and may contribute to its progression by promoting insulin resistance and dysglycemia.
Collapse
Affiliation(s)
- Martin H Lundqvist
- Clinical Diabetology and Metabolism, Department of Medical Sciences, Uppsala University, 751 85 Uppsala, Sweden
| | - Maria J Pereira
- Clinical Diabetology and Metabolism, Department of Medical Sciences, Uppsala University, 751 85 Uppsala, Sweden
| | - Kristina Almby
- Clinical Diabetology and Metabolism, Department of Medical Sciences, Uppsala University, 751 85 Uppsala, Sweden
| | - Susanne Hetty
- Clinical Diabetology and Metabolism, Department of Medical Sciences, Uppsala University, 751 85 Uppsala, Sweden
| | - Jan W Eriksson
- Clinical Diabetology and Metabolism, Department of Medical Sciences, Uppsala University, 751 85 Uppsala, Sweden
| |
Collapse
|
3
|
Bjerkan KK, Sandvik J, Nymo S, Johnsen G, Hyldmo ÅA, Kulseng BE, Salater S, Høydal KL, Hoff DAL. Postbariatric hypoglycemia, abdominal pain and gastrointestinal symptoms after Roux-en-Y gastric bypass explored by continuous glucose monitoring. Obes Res Clin Pract 2024; 18:9-14. [PMID: 38402034 DOI: 10.1016/j.orcp.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 02/12/2024] [Accepted: 02/15/2024] [Indexed: 02/26/2024]
Abstract
BACKGROUND Abdominal pain and postbariatric hypoglycemia (PBH) are common after bariatric surgery. OBJECTIVES This study aimed to explore the potential relationship between abdominal pain, gastrointestinal symptoms, and PBH more than a decade after Roux-en-Y gastric bypass (RYGB) and whether continuous glucose monitoring (CGM) with dietary intervention has an educational role in reducing symptoms. SUBJECTS At two public hospitals in Norway (one University Hospital) 22 of 46 invited patients who reported abdominal pain more than weekly took part. Recruited from a prospective follow-up study of 546 patients 14.5 years after RYGB. METHODS They used a CGM for two 14-day periods, with a dietary intervention between periods. The Gastrointestinal Symptom Rating Scale (GSRS) and the Dumping Severity Score (DSS) questionnaires were completed at the start and end of the study. RESULTS The 22 women had preoperative age 39.6 ± 7.7 years and body mass index (BMI) 42.0 ± 4.0 kg/m2, present age 54.6 ± 7.7 years and BMI 29.8 ± 4.8 kg/m2. The total GSRS score and DSS of early dumping decreased after the diet intervention. The number of events with Level 1 (<3.9 mmol/L) or Level 2 (<3.0 mmol/L) hypoglycemia did not change in the second period. Half of the patients had fewer, three had unchanged, and eight had more frequent events with Level 1 hypoglycemia after the intervention. Ten patients had Level 2 hypoglycemia. CONCLUSION Though inconclusive findings, a personalized dietary intervention reduces GSRS. This intervention was accompanied by lower mean absolute glucose in patients with recurrent abdominal pain after bariatric surgery. However, further studies are needed to explore the benefits of CGM in this setting.
Collapse
Affiliation(s)
- Kirsti K Bjerkan
- Faculty of Social Science and History, Volda University College, Volda, Norway; Department of Surgery, Møre and Romsdal Hospital Trust, Ålesund, Norway.
| | - Jorunn Sandvik
- Department of Surgery, Møre and Romsdal Hospital Trust, Ålesund, Norway; Centre for Obesity Research, Clinic of Surgery, St. Olav's University Hospital, Trondheim, Norway; Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Siren Nymo
- Centre for Obesity Research, Clinic of Surgery, St. Olav's University Hospital, Trondheim, Norway; Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway; Clinic of Surgery, Namsos Hospital, Nord-Trøndelag Hospital Trust, Norway
| | - Gjermund Johnsen
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway; Norwegian National Advisory Unit on Advanced Laparoscopic Surgery, Clinic of Surgery, St.Olav's University Hospital, Trondheim, Norway
| | - Åsne A Hyldmo
- Centre for Obesity Research, Clinic of Surgery, St. Olav's University Hospital, Trondheim, Norway; Department of Clinical Studies, Møre and Romsdal Hospital Trust, Ålesund, Norway
| | - Bård Eirik Kulseng
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Sissel Salater
- Centre for Obesity Research, Clinic of Surgery, St. Olav's University Hospital, Trondheim, Norway
| | - Kjetil Laurits Høydal
- Department of Physical Education, Faculty of Arts and Physical Education, Volda University College, Volda, Norway
| | - Dag Arne L Hoff
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway; Department of Clinical Studies, Møre and Romsdal Hospital Trust, Ålesund, Norway; Department of Health Sciences, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Ålesund, Norway
| |
Collapse
|
4
|
Nielsen CK, Øhrstrøm CC, Houji IJK, Helsted MM, Krogh LSL, Johansen NJ, Hartmann B, Holst JJ, Vilsbøll T, Knop FK. Dasiglucagon Treatment for Postprandial Hypoglycemia After Gastric Bypass: A Randomized, Double-Blind, Placebo-Controlled Trial. Diabetes Care 2023; 46:2208-2217. [PMID: 37819999 DOI: 10.2337/dc23-1193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 09/11/2023] [Indexed: 10/13/2023]
Abstract
OBJECTIVE Postbariatric hypoglycemia affects >50% of individuals who have undergone Roux-en-Y gastric bypass surgery. Despite the often debilitating nature of this complication, existing treatment options are limited and often inefficient. Dasiglucagon is a stable glucagon analog available in a ready-to-use formulation and was recently shown to mitigate postbariatric hypoglycemia in experimental settings. Here, we aimed to evaluate the hypoglycemic hindering potential of dasiglucagon in an outpatient trial. RESEARCH DESIGN AND METHODS We conducted a randomized, double-blind, placebo-controlled, crossover, proof-of-concept study at the Center for Clinical Metabolic Research at Gentofte Hospital in Denmark. The study included 24 individuals who had undergone Roux-en-Y gastric bypass surgery (n = 23 women) with continuous glucose monitor-verified postbariatric hypoglycemia (≥15 min at <3.9 mmol/L three or more times per week) randomly assigned to two treatment periods of 4 weeks of self-administered subcutaneous dasiglucagon at 120 μg or placebo. The primary and key secondary outcomes were continuous glucose monitor-captured percentage of time in level 1 and 2 hypoglycemia (<3.9 and <3.0 mmol/L), respectively. RESULTS Compared with placebo, treatment with dasiglucagon significantly reduced time in level 1 hypoglycemia by 33% (-1.2 percentage points; 95% CI -2.0 to -0.5; P = 0.002) and time in level 2 hypoglycemia by 54% (-0.4 percentage points; 95% CI -0.6 to -0.2; P < 0.0001). Furthermore, dasiglucagon corrected hypoglycemia within 15 min in 401 of 412 self-administrations, compared with 104 of 357 placebo self-administrations (97.3% vs. 29.1% correction of hypoglycemia rate; P < 0.001). Dasiglucagon was generally well tolerated, with mostly mild to moderate adverse events of nausea. CONCLUSIONS Compared with placebo, 4 weeks of self-administered dasiglucagon effectively reduced clinically relevant hypoglycemia in individuals who had undergone Roux-en-Y gastric bypass surgery.
Collapse
Affiliation(s)
- Casper K Nielsen
- Center for Clinical Metabolic Research, Copenhagen University Hospital-Herlev and Gentofte, Hellerup, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | | | - Inas J K Houji
- Center for Clinical Metabolic Research, Copenhagen University Hospital-Herlev and Gentofte, Hellerup, Denmark
| | - Mads M Helsted
- Center for Clinical Metabolic Research, Copenhagen University Hospital-Herlev and Gentofte, Hellerup, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Liva S L Krogh
- Center for Clinical Metabolic Research, Copenhagen University Hospital-Herlev and Gentofte, Hellerup, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Nicklas J Johansen
- Center for Clinical Metabolic Research, Copenhagen University Hospital-Herlev and Gentofte, Hellerup, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Bolette Hartmann
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jens J Holst
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Tina Vilsbøll
- Center for Clinical Metabolic Research, Copenhagen University Hospital-Herlev and Gentofte, Hellerup, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Clinical Research, Steno Diabetes Center Copenhagen, Herlev, Denmark
| | - Filip K Knop
- Center for Clinical Metabolic Research, Copenhagen University Hospital-Herlev and Gentofte, Hellerup, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Clinical Research, Steno Diabetes Center Copenhagen, Herlev, Denmark
| |
Collapse
|
5
|
Jalleh RJ, Umapathysivam MM, Plummer MP, Deane A, Jones KL, Horowitz M. Postprandial plasma GLP-1 levels are elevated in individuals with postprandial hypoglycaemia following Roux-en-Y gastric bypass - a systematic review. Rev Endocr Metab Disord 2023; 24:1075-1088. [PMID: 37439960 PMCID: PMC10697890 DOI: 10.1007/s11154-023-09823-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/28/2023] [Indexed: 07/14/2023]
Abstract
BACKGROUND AND AIMS Bariatric surgery is the most effective treatment in individuals with obesity to achieve remission of type 2 diabetes. Post-bariatric surgery hypoglycaemia occurs frequently, and management remains suboptimal, because of a poor understanding of the underlying pathophysiology. The glucoregulatory hormone responses to nutrients in individuals with and without post-bariatric surgery hypoglycaemia have not been systematically examined. MATERIALS AND METHODS The study protocol was prospectively registered with PROSPERO. PubMed, EMBASE, Web of Science and the Cochrane databases were searched for publications between January 1990 and November 2021 using MeSH terms related to post-bariatric surgery hypoglycaemia. Studies were included if they evaluated individuals with post-bariatric surgery hypoglycaemia and included measurements of plasma glucagon-like peptide-1 (GLP-1), glucose-dependent insulinotropic polypeptide (GIP), insulin, C-peptide and/or glucagon concentrations following an ingested nutrient load. Glycated haemoglobin (HbA1c) was also evaluated. A random-effects meta-analysis was performed, and Hedges' g (standardised mean difference) and 95% confidence intervals were reported for all outcomes where sufficient studies were available. The τ2 estimate and I2 statistic were used as tests for heterogeneity and a funnel plot with the Egger regression-based test was used to evaluate for publication bias. RESULTS From 377 identified publications, 12 were included in the analysis. In all 12 studies, the type of bariatric surgery was Roux-en-Y gastric bypass (RYGB). Comparing individuals with and without post-bariatric surgery hypoglycaemia following an ingested nutrient load, the standardised mean difference in peak GLP-1 was 0.57 (95% CI, 0.32, 0.82), peak GIP 0.05 (-0.26, 0.36), peak insulin 0.84 (0.44, 1.23), peak C-peptide 0.69 (0.28, 1.1) and peak glucagon 0.05 (-0.26, 0.36). HbA1c was less in individuals with hypoglycaemia - 0.40 (-0.67, -0.12). There was no evidence of substantial heterogeneity in any outcome except for peak insulin: τ2 = 0.2, I2 = 54.3. No publication bias was evident. CONCLUSION Following RYGB, postprandial peak plasma GLP-1, insulin and C-peptide concentrations are greater in individuals with post-bariatric surgery hypoglycaemia, while HbA1c is less. These observations support the concept that antagonism of GLP-1 would prove beneficial in the management of individuals with hypoglycaemia following RYGB.PROSPERO Registration Number: CRD42021287515.
Collapse
Affiliation(s)
- Ryan Joseph Jalleh
- Adelaide Medical School, The University of Adelaide, South Australia, Australia
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, South Australia, Australia
- Diabetes and Endocrine Services, Northern Adelaide Local Health Network, South Australia, Australia
| | - Mahesh Michael Umapathysivam
- Adelaide Medical School, The University of Adelaide, South Australia, Australia
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, South Australia, Australia
| | - Mark Philip Plummer
- Adelaide Medical School, The University of Adelaide, South Australia, Australia
| | - Adam Deane
- Intensive Care Unit, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Karen Louise Jones
- Adelaide Medical School, The University of Adelaide, South Australia, Australia
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, South Australia, Australia
| | - Michael Horowitz
- Adelaide Medical School, The University of Adelaide, South Australia, Australia.
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, South Australia, Australia.
| |
Collapse
|
6
|
Ternhamar T, Møller A, Martinussen C, Svane MS, Hindsø M, Jørgensen NB, Dirksen C, Jensen JEB, Hartmann B, Holst JJ, Kiens B, Madsbad S, Bojsen-Møller KN. The effects of postprandial exercise and meal glycemic index on plasma glucose and glucoregulatory hormone responses after Roux-en-Y gastric bypass. Am J Physiol Endocrinol Metab 2023; 325:E540-E551. [PMID: 37755455 DOI: 10.1152/ajpendo.00176.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 09/18/2023] [Accepted: 09/18/2023] [Indexed: 09/28/2023]
Abstract
Postprandial hypoglycemia is a complication of Roux-en-Y gastric bypass (RYGB), but the effects of postprandial exercise and meal glycemic index (GI) on postprandial glucose and glucoregulatory hormone responses are unknown. Ten RYGB-operated and 10 age and weight-matched unoperated women completed four test days in random order ingesting mixed meals with high GI (HGI, GI = 93) or low GI (LGI, GI = 54), but matched on energy and macronutrient content. Ten minutes after meal completion, participants rested or cycled for 30 min at 70% of maximum oxygen uptake (V̇o2max). Blood was collected for 4 h. Postprandial exercise did not lower plasma nadir glucose in RYGB after HGI (HGI/rest 3.7 ± 0.5 vs. HGI/Ex 4.1 ± 0.4 mmol/L, P = 0.070). Replacing HGI with LGI meals raised glucose nadir in RYGB (LGI/rest 4.1 ± 0.5 mmol/L, P = 0.034) and reduced glucose excursions (Δpeak-nadir) but less so in RYGB (-14% [95% CI: -27; -1]) compared with controls (-33% [-51; -14]). Insulin responses mirrored glucose concentrations. Glucagon-like peptide 1 (GLP-1) responses were greater in RYGB versus controls, and higher with HGI versus LGI. Glucose-dependent insulinotropic polypeptide (GIP) responses were greater after HGI versus LGI in both groups. Postexercise glucagon responses were lower in RYGB than controls, and noradrenaline responses tended to be lower in RYGB, whereas adrenaline responses were similar between groups. In conclusion, moderate intensity cycling shortly after meal intake did not increase the risk of postprandial hypoglycemia after RYGB. The low GI meal increased nadir glucose and reduced glucose excursions compared with the high GI meal. RYGB participants had lower postexercise glucagon responses compared with controls.NEW & NOTEWORTHY We investigate the effect of moderate exercise after a high or a low glycemic index meal on nadir glucose and glucoregulatory hormones in gastric bypass-operated individuals and in matched unoperated controls. Cycling shortly after meal intake did not increase the risk of hypoglycemia in operated individuals. The low glycemic index meal increased glucose nadir and reduced excursions compared with the high glycemic index meal. Operated individuals had lower postexercise glucagon responses compared with controls.
Collapse
Affiliation(s)
- Tummas Ternhamar
- Department of Endocrinology, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Andreas Møller
- Department of Endocrinology, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | | | - Maria S Svane
- Department of Endocrinology, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Morten Hindsø
- Department of Endocrinology, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Nils B Jørgensen
- Department of Endocrinology, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Carsten Dirksen
- Department of Endocrinology, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Jens-Erik Beck Jensen
- Department of Endocrinology, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
- Institute of Clinical Medicine, Faculty of Health, University of Copenhagen, Copenhagen, Denmark
| | - Bolette Hartmann
- Department of Biomedical Sciences, Faculty of Health, University of Copenhagen, Copenhagen, Denmark
| | - Jens J Holst
- Department of Biomedical Sciences, Faculty of Health, University of Copenhagen, Copenhagen, Denmark
| | - Bente Kiens
- Department of Nutrition, Exercise, and Sports, Faculty of Science, University of Copenhagen, Copenhagen, Denmark
| | - Sten Madsbad
- Department of Endocrinology, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | | |
Collapse
|
7
|
Salehi M, Tripathy D, Peterson R, Honka H, Pezzica S, DeFronzo R, Gastaldelli A. Bariatric Surgery Alters the Postprandial Recovery From Hypoglycemia, Mediated by Cholinergic Signal. Diabetes 2023; 72:1374-1383. [PMID: 37467435 PMCID: PMC10545558 DOI: 10.2337/db23-0207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 07/03/2023] [Indexed: 07/21/2023]
Abstract
Roux-en-Y gastric bypass (GB) and sleeve gastrectomy (SG) surgeries increase prandial insulin and glucagon secretion but reduce the endogenous glucose production (EGP) response to hypoglycemia in comparison with control subjects who had not undergone gastric surgery (CN), suggesting that parasympathetic nervous system (PNS) plays a role. Here, we investigated the effect of acute PNS blockade on the post-meal counterregulatory response to insulin-induced hypoglycemia in GB and SG compared with CN. Glucose kinetics and islet cell secretion were measured in nine subjects without diabetes with GB and seven with SG and five CN during hyperinsulinemic-hypoglycemic clamp (∼3.2 mmol/L) combined with meal ingestion on two separate days with and without intravenous atropine infusion. Glucose and hormonal levels were similar at baseline and during steady-state hypoglycemia before meal ingestion in three groups and unaffected by atropine. Atropine infusion diminished prandial systemic appearance of ingested glucose (RaO) by 30%, EGP by 40%, and glucagon response to hypoglycemia by 90% in CN. In GB or SG, blocking PNS had no effect on the RaO or meal-induced hyperglucagonemia but increased EGP in SG without any effect in GB (P < 0.05 interaction). These findings indicate that cholinergic signal contributes to the recovery from hypoglycemia by meal consumption in humans. However, bariatric surgery dissipates PNS-mediated physiologic responses to hypoglycemia in the fed state. ARTICLE HIGHLIGHTS Rerouted gut after Roux-en-Y gastric bypass (GB) and, to a lesser degree, after sleeve gastrectomy (SG) leads to larger glucose excursion and lower nadir glucose, predisposing individuals to hypoglycemia. Despite prandial hyperglucagonemia, endogenous glucose production response to hypoglycemia is reduced after GB or SG. Parasympathetic nervous system (PNS) activity plays a key role in regulation of glucose kinetics and islet cell function. We examined the effect of acute PNS blockade on counterregulatory glucose and islet cell response to meal ingestion during insulin-induced hypoglycemia among GB, SG, and control subjects who had not had gastric surgery. Our findings demonstrate that cholinergic signal is critical in the recovery from hypoglycemia by meal ingestion in humans who have not had gastric surgery, although prandial PNS-mediated physiologic responses to hypoglycemia are differentially changed by GB and SG.
Collapse
Affiliation(s)
- Marzieh Salehi
- Division of Diabetes, The University of Texas at San Antonio, San Antonio, TX
- Audie L. Murphy Memorial Veterans’ Hospital, South Texas Veterans Health Care System, San Antonio, TX
| | - Devjit Tripathy
- Division of Diabetes, The University of Texas at San Antonio, San Antonio, TX
| | - Richard Peterson
- Department of Surgery, The University of Texas at San Antonio, San Antonio, TX
| | - Henri Honka
- Division of Diabetes, The University of Texas at San Antonio, San Antonio, TX
| | - Samantha Pezzica
- Cardiometabolic Risk Unit, CNR Institute of Clinical Physiology, Pisa, Italy
| | - Ralph DeFronzo
- Division of Diabetes, The University of Texas at San Antonio, San Antonio, TX
| | - Amalia Gastaldelli
- Division of Diabetes, The University of Texas at San Antonio, San Antonio, TX
- Cardiometabolic Risk Unit, CNR Institute of Clinical Physiology, Pisa, Italy
| |
Collapse
|
8
|
Ostrovsky V, Knobler H, Lazar LO, Pines G, Kuniavsky T, Cohen L, Schiller T, Kirzhner A, Zornitzki T. Persistent post-bariatric-surgery hypoglycemia: A long-term follow-up reassessment. Nutr Metab Cardiovasc Dis 2023; 33:1197-1205. [PMID: 36948939 DOI: 10.1016/j.numecd.2023.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 01/28/2023] [Accepted: 02/15/2023] [Indexed: 03/24/2023]
Abstract
BACKGROUND AND AIM Post-bariatric-surgery hypoglycemia (PBH) is a serious complication of bariatric surgery (BS). In our previous study about three quarters of the patients developed PBH. However long-term follow-up data is lacking to determine whether this condition improves with time. The aim of the current study was to re-assess post-BS patients who participated in our previous study and determine whether there are changes in the frequency and/or severity of hypoglycemic events. METHODS AND RESULTS Twenty-four post-BS, post Roux-en-Y gastric-bypass (RYGB = 10), post omega-loop gastric-bypass (OLGB = 9) and post sleeve-gastrectomy (SG = 5) individuals were reevaluated in a follow-up study 34.4 ± 4 months after their previous assessment and 67 ± 17 months since surgery. The evaluation included: a dietitian assessment, a questionnaire, meal-tolerance test (MTT) and a one-week masked continuous glucose monitoring (CGM). Hypoglycemia and severe hypoglycemia were defined by glucose levels ≤54 mg/dl and ≤40 mg/dl, respectively. Thirteen patients reported questionnaire meal-related complaints, mainly non-specific. During MTT, hypoglycemia occurred in 75% of the patients, and severe hypoglycemia in a third, but none was associated with specific complaints. During CGM, 66% of patients developed hypoglycemia and 37% had severe hypoglycemia. We did not observe significant improvements in hypoglycemic events compared to the previous assessment. Despite the high frequency of hypoglycemia, it did not necessitate hospitalizations or lead to death. CONCLUSIONS PBH did not resolve within long-term follow-up. Intriguingly, most patient were unaware of these events which can lead to underestimation by the medical staff. Further studies are needed to determine possible long term sequela of repeated hypoglycemia.
Collapse
Affiliation(s)
- Viviana Ostrovsky
- Diabetes, Endocrinology and Metabolic Disease Institute, Kaplan Medical Center, Rehovot, Hebrew University of Jerusalem, The Faculty of Medicine, Israel.
| | - Hilla Knobler
- Diabetes, Endocrinology and Metabolic Disease Institute, Kaplan Medical Center, Rehovot, Hebrew University of Jerusalem, The Faculty of Medicine, Israel
| | - Li Or Lazar
- Surgery Department, Kaplan Medical Center, Rehovot, Hebrew University of Jerusalem, The Faculty of Medicine, Israel
| | - Guy Pines
- Surgery Department, Kaplan Medical Center, Rehovot, Hebrew University of Jerusalem, The Faculty of Medicine, Israel
| | - Tamila Kuniavsky
- Diabetes, Endocrinology and Metabolic Disease Institute, Kaplan Medical Center, Rehovot, Hebrew University of Jerusalem, The Faculty of Medicine, Israel
| | - Lee Cohen
- Diabetes, Endocrinology and Metabolic Disease Institute, Kaplan Medical Center, Rehovot, Hebrew University of Jerusalem, The Faculty of Medicine, Israel
| | - Tal Schiller
- Diabetes, Endocrinology and Metabolic Disease Institute, Kaplan Medical Center, Rehovot, Hebrew University of Jerusalem, The Faculty of Medicine, Israel
| | - Alena Kirzhner
- Diabetes, Endocrinology and Metabolic Disease Institute, Kaplan Medical Center, Rehovot, Hebrew University of Jerusalem, The Faculty of Medicine, Israel
| | - Taiba Zornitzki
- Diabetes, Endocrinology and Metabolic Disease Institute, Kaplan Medical Center, Rehovot, Hebrew University of Jerusalem, The Faculty of Medicine, Israel
| |
Collapse
|
9
|
Tripyla A, Herzig D, Reverter-Branchat G, Pavan J, Schiavon M, Eugster PJ, Grouzmann E, Nakas CT, Sauvinet V, Meiller L, Zehetner J, Giachino D, Nett P, Gawinecka J, Del Favero S, Thomas A, Thevis M, Dalla Man C, Bally L. Counter-regulatory responses to postprandial hypoglycaemia in patients with post-bariatric hypoglycaemia vs surgical and non-surgical control individuals. Diabetologia 2023; 66:741-753. [PMID: 36648553 PMCID: PMC9947092 DOI: 10.1007/s00125-022-05861-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 11/21/2022] [Indexed: 01/18/2023]
Abstract
AIMS/HYPOTHESIS Post-bariatric hypoglycaemia is an increasingly recognised complication of bariatric surgery, manifesting particularly after Roux-en-Y gastric bypass. While hyperinsulinaemia is an established pathophysiological feature, the role of counter-regulation remains unclear. We aimed to assess counter-regulatory hormones and glucose fluxes during insulin-induced postprandial hypoglycaemia in patients with post-bariatric hypoglycaemia after Roux-en-Y gastric bypass vs surgical and non-surgical control individuals. METHODS In this case-control study, 32 adults belonging to four groups with comparable age, sex and BMI (patients with post-bariatric hypoglycaemia, Roux-en-Y gastric bypass, sleeve gastrectomy and non-surgical control individuals) underwent a postprandial hypoglycaemic clamp in our clinical research unit to reach the glycaemic target of 2.5 mmol/l 150-170 min after ingesting 15 g of glucose. Glucose fluxes were assessed during the postprandial and hypoglycaemic period using a dual-tracer approach. The primary outcome was the incremental AUC of glucagon during hypoglycaemia. Catecholamines, cortisol, growth hormone, pancreatic polypeptide and endogenous glucose production were also analysed during hypoglycaemia. RESULTS The rate of glucose appearance after oral administration, as well as the rates of total glucose appearance and glucose disappearance, were higher in both Roux-en-Y gastric bypass groups vs the non-surgical control group in the early postprandial period (all p<0.05). During hypoglycaemia, glucagon exposure was significantly lower in all surgical groups vs the non-surgical control group (all p<0.01). Pancreatic polypeptide levels were significantly lower in patients with post-bariatric hypoglycaemia vs the non-surgical control group (median [IQR]: 24.7 [10.9, 38.7] pmol/l vs 238.7 [186.3, 288.9] pmol/l) (p=0.005). Other hormonal responses to hypoglycaemia and endogenous glucose production did not significantly differ between the groups. CONCLUSIONS/INTERPRETATION The glucagon response to insulin-induced postprandial hypoglycaemia is lower in post-bariatric surgery individuals compared with non-surgical control individuals, irrespective of the surgical modality. No significant differences were found between patients with post-bariatric hypoglycaemia and surgical control individuals, suggesting that impaired counter-regulation is not a root cause of post-bariatric hypoglycaemia. TRIAL REGISTRATION ClinicalTrials.gov NCT04334161.
Collapse
Affiliation(s)
- Afroditi Tripyla
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - David Herzig
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Gemma Reverter-Branchat
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jacopo Pavan
- Department of Information Engineering, University of Padova, Padova, Italy
| | - Michele Schiavon
- Department of Information Engineering, University of Padova, Padova, Italy
| | - Philippe J Eugster
- Laboratory of Catecholamines and Peptides, Service of Clinical Pharmacology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Eric Grouzmann
- Laboratory of Catecholamines and Peptides, Service of Clinical Pharmacology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Christos T Nakas
- School of Agricultural Sciences, Laboratory of Biometry, University of Thessaly, Volos, Greece
- University Institute of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Valérie Sauvinet
- Centre de Recherche Nutrition Humaine Rhône-Alpes, Univ-Lyon, Inserm, INRAe, Claude Bernard Lyon1 University, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre Bénite, France
| | - Laure Meiller
- Centre de Recherche Nutrition Humaine Rhône-Alpes, Univ-Lyon, Inserm, INRAe, Claude Bernard Lyon1 University, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre Bénite, France
| | - Joerg Zehetner
- Department of Visceral Surgery, Hirslanden Clinic Beau-Site, Bern, Switzerland
| | - Daniel Giachino
- Department of Visceral Surgery, Lindenhofspital, Bern, Switzerland
| | - Philipp Nett
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Joanna Gawinecka
- Institute of Clinical Chemistry, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Simone Del Favero
- Department of Information Engineering, University of Padova, Padova, Italy
| | - Andreas Thomas
- Institute of Biochemistry / Center for Preventive Doping Research, German Sport University Cologne, Cologne, Germany
| | - Mario Thevis
- Institute of Biochemistry / Center for Preventive Doping Research, German Sport University Cologne, Cologne, Germany
| | - Chiara Dalla Man
- Department of Information Engineering, University of Padova, Padova, Italy
| | - Lia Bally
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| |
Collapse
|
10
|
Palani G, Stortz E, Moheet A. Clinical Presentation and Diagnostic Approach to Hypoglycemia in Adults Without Diabetes Mellitus. Endocr Pract 2023; 29:286-294. [PMID: 36464132 DOI: 10.1016/j.eprac.2022.11.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 10/24/2022] [Accepted: 11/28/2022] [Indexed: 12/03/2022]
Abstract
OBJECTIVE To review the clinical presentation, causes, and diagnostic approach to spontaneous hypoglycemia in adults without diabetes mellitus. METHODS A literature review was performed using the PubMed and Google Scholar databases. RESULTS Hypoglycemia is uncommon in people who are not on glucose-lowering medications. Under normal physiologic conditions, multiple neural and hormonal counterregulatory mechanisms prevent the development of abnormally low levels of plasma glucose. If spontaneous hypoglycemia is suspected, the Whipple triad should be used to confirm hypoglycemia before pursuing further diagnostic workup. The Whipple criteria include the following: (1) low levels of plasma glucose, (2) signs or symptoms that would be expected with low levels of plasma glucose, and (3) improvement in those signs or symptoms when the level of plasma glucose increases. Spontaneous hypoglycemia can be caused by conditions that cause endogenous hyperinsulinism, including insulinoma, postbariatric hypoglycemia, and noninsulinoma pancreatogenous hypoglycemia. Spontaneous hypoglycemia can also be seen with critical illness, hepatic or renal dysfunction, hormonal deficiency, non-diabetes-related medications, and non-islet cell tumors. The initial diagnostic approach should begin by obtaining a detailed history of the nature and timing of the patient's symptoms, medications, underlying comorbid conditions, and any acute illness. A laboratory evaluation should be conducted at the time of the spontaneous symptomatic episode. Supervised tests such as a 72-hour fast or mixed-meal test may be needed to recreate the situation under which the patient is likely to experience symptoms. CONCLUSION We provide an overview of the physiology of counterregulatory response to hypoglycemia, its causes, and diagnostic approaches to spontaneous hypoglycemia in adults.
Collapse
Affiliation(s)
- Gurunanthan Palani
- Division of Endocrinology and Diabetes, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Ethan Stortz
- Division of Endocrinology and Diabetes, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Amir Moheet
- Division of Endocrinology and Diabetes, Department of Medicine, University of Minnesota, Minneapolis, Minnesota.
| |
Collapse
|
11
|
Eriksson JW, Emad RA, Lundqvist MH, Abrahamsson N, Kjellsson MC. Altered glucose-dependent secretion of glucagon and ACTH is associated with insulin resistance, assessed by population analysis. Endocr Connect 2023; 12:e220506. [PMID: 36752854 PMCID: PMC10083665 DOI: 10.1530/ec-22-0506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 02/08/2023] [Indexed: 02/09/2023]
Abstract
This study aimed to characterize how the dysregulation of counter-regulatory hormones can contribute to insulin resistance and potentially to diabetes. Therefore, we investigated the association between insulin sensitivity and the glucose- and insulin-dependent secretion of glucagon, adrenocorticotropic hormone (ACTH), and cortisol in non-diabetic individuals using a population model analysis. Data, from hyperinsulinemic-hypoglycemic clamps, were pooled for analysis, including 52 individuals with a wide range of insulin resistance (reflected by glucose infusion rate 20-60 min; GIR20-60min). Glucagon secretion was suppressed by glucose and, to a lesser extent, insulin. The GIR20-60min and BMI were identified as predictors of the insulin effect on glucagon. At normoglycemia (5 mmol/L), a 90% suppression of glucagon was achieved at insulin concentrations of 16.3 and 43.4 µU/mL in individuals belonging to the highest and lowest quantiles of insulin sensitivity, respectively. Insulin resistance of glucagon secretion explained the elevated fasting glucagon for individuals with a low GIR20-60min. ACTH secretion was suppressed by glucose and not affected by insulin. The GIR20-60min was superior to other measures as a predictor of glucose-dependent ACTH secretion, with 90% suppression of ACTH secretion by glucose at 3.1 and 3.5 mmol/L for insulin-sensitive and insulin-resistant individuals, respectively. This difference may appear small but shifts the suppression range into normoglycemia for individuals with insulin resistance, thus, leading to earlier and greater ACTH/cortisol response when the glucose falls. Based on modeling of pooled glucose-clamp data, insulin resistance was associated with generally elevated glucagon and a potentiated cortisol-axis response to hypoglycemia, and over time both hormonal pathways may therefore contribute to dysglycemia and possibly type 2 diabetes.
Collapse
Affiliation(s)
- Jan W Eriksson
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Reem A Emad
- Department of Pharmacy, Uppsala University, Uppsala, Sweden
| | | | | | | |
Collapse
|
12
|
Patience N, Sheehan A, Cummings C, Patti ME. Medical Nutrition Therapy and Other Approaches to Management of Post-bariatric Hypoglycemia: A Team-Based Approach. Curr Obes Rep 2022; 11:277-286. [PMID: 36074258 DOI: 10.1007/s13679-022-00482-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/26/2022] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW This manuscript provides a review of post-bariatric hypoglycemia (PBH) with a special focus on the role of the registered dietitian-nutritionist (RDN) and medical nutrition therapy (MNT) recommendations as foundational for management. RECENT FINDINGS As the number of bariatric surgeries rises yearly, with 256,000 performed in 2019, PBH is an increasingly encountered late complication. Following Roux-en-Y (RYGB) or vertical sleeve gastrectomy (VSG), about 1/3 of patients report symptoms suggestive of at least mild postprandial hypoglycemia, with severe and/or medically confirmed hypoglycemia in 1-10%. Anatomical alterations, changes in GLP1 and other intestinally derived hormones, excessive insulin response, reduced insulin clearance, impaired counterregulatory hormone response to hypoglycemia, and other factors contribute to PBH. MNT is the cornerstone of multidisciplinary treatment, with utilization of personal continuous glucose monitoring to improve safety when possible. While many individuals require pharmacotherapy, there are no currently approved medications for PBH. Increasing awareness and identification of individuals at risk for or with PBH is critical given the potential impact on safety, nutrition, and quality of life. A team-based approach involving the individual, the RDN, and other clinicians is essential in providing ongoing assessment and individualization of MNT in the long-term management of PBH.
Collapse
Affiliation(s)
- Nicole Patience
- Clinic Division, Joslin Diabetes Center, Inc, One Joslin Place, Boston, MA, 02215, USA.
| | - Amanda Sheehan
- Clinic Division, Joslin Diabetes Center, Inc, One Joslin Place, Boston, MA, 02215, USA
- Research Division, Joslin Diabetes Center, Boston, MA, USA
| | | | - Mary Elizabeth Patti
- Clinic Division, Joslin Diabetes Center, Inc, One Joslin Place, Boston, MA, 02215, USA.
- Research Division, Joslin Diabetes Center, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
| |
Collapse
|
13
|
Lee CJ, Clark JM, Egan JM, Carlson OD, Schweitzer M, Langan S, Brown T. Comparison of Hormonal Response to a Mixed-Meal Challenge in Hypoglycemia After Sleeve Gastrectomy vs Gastric Bypass. J Clin Endocrinol Metab 2022; 107:e4159-e4166. [PMID: 35914520 PMCID: PMC9516126 DOI: 10.1210/clinem/dgac455] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Indexed: 11/19/2022]
Abstract
CONTEXT Exaggerated postprandial incretin and insulin responses are well documented in postbariatric surgery hypoglycemia (PBH) after Roux-en-Y gastric bypass (RYGB). However, less is known about PBH after sleeve gastrectomy (SG). OBJECTIVE We sought to compare meal-stimulated hormonal response in those with PBH after SG vs RYGB. METHODS We enrolled 23 post-SG (12 with and 11 without PBH) and 20 post-RYGB (7 with and 13 without PBH) individuals who underwent bariatric surgery at our institution. PBH was defined as plasma glucose less than 60 mg/dL on 4-hour mixed-meal tolerance test (MTT). Islet and incretin hormones were compared across the 4 groups. RESULTS Participants (N = 43) were on average 5 years post surgery, with a mean age of 48 years, mean preoperative body mass index of 48.4, 81% female, 61% White, and 53% post SG. Regardless of PBH, the SG group showed lower glucose, glucagon, and glucagon-like peptide 1 (GLP-1) responses to MTT and similar insulin and glucose-dependent insulinotropic polypeptide (GIP) responses compared to the RYGB group. Among those with PBH, the SG group following the MTT showed a lower peak glucose (P = .02), a similar peak insulin (90.3 mU/L vs 171mU/L; P = .18), lower glucagon (P < .01), early GLP-1 response (AUC0-60 min; P = .01), and slower time to peak GIP (P = .02) compared to PBH after RYGB. CONCLUSION Among individuals with PBH, those who underwent SG were significantly different compared to RYGB in meal-stimulated hormonal responses, including lower glucagon and GLP-1 responses, but similar insulin and GIP responses. Future studies are needed to better understand the differential contribution of insulin and non-insulin-mediated mechanisms behind PBH after SG vs RYGB.
Collapse
Affiliation(s)
- Clare J Lee
- Correspondence: Clare J. Lee, MD, MHS, Division of Endocrinology and Metabolism, The Johns Hopkins University, 1830 E Monument St, Ste 333, Baltimore, MD 21287, USA.
| | - Jeanne M Clark
- Division of General Internal Medicine, Department of Medicine, The Johns Hopkins University, Baltimore, Maryland 21287, USA
- Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland 21287, USA
| | - Josephine M Egan
- National Institute On Aging, National Institutes of Health, Baltimore, Maryland 21224, USA
| | - Olga D Carlson
- National Institute On Aging, National Institutes of Health, Baltimore, Maryland 21224, USA
| | - Michael Schweitzer
- Department of Surgery, The Johns Hopkins University, Baltimore, Maryland 21287, USA
| | - Susan Langan
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, The Johns Hopkins University, Baltimore, Maryland 21287, USA
| | - Todd Brown
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, The Johns Hopkins University, Baltimore, Maryland 21287, USA
| |
Collapse
|
14
|
Ferreira A, Emara AFA, Herzig D, Melmer A, Vogt AP, Nakas CT, Facchinetti A, Dalla Man C, Bally L. Study protocol for a randomised, double-blind, placebo-controlled crossover trial assessing the impact of the SGLT2 inhibitor empagliflozin on postprandial hypoglycaemia after gastric bypass. BMJ Open 2022; 12:e060668. [PMID: 36123073 PMCID: PMC9486284 DOI: 10.1136/bmjopen-2021-060668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Postprandial hypoglycaemia after gastric bypass surgery (also known as postbariatric hypoglycaemia or PBH) is an increasingly encountered clinical problem. PBH is characterised by meal-induced rapid spikes and consequent falls in glycaemia, resulting in both hypoglycaemia burden and high glycaemic variability. Despite its frequency, there is currently no approved pharmacotherapy. The purpose of this investigation is to evaluate efficacy and safety of empagliflozin 25 mg, a sodium-glucose cotransporter 2-inhibitor, to reduce glucose excursions and hypoglycaemia burden in patients with PBH after gastric bypass surgery. METHODS AND ANALYSIS In a prospective, single-centre, randomised, double-blind, placebo-controlled, crossover trial, we plan to enrol 22 adults (≥18 years) with PBH after Roux-en-Y gastric bypass surgery (plasma or sensor glucose <3.0 mmol/L). Eligible patients will be randomised to receive empagliflozin 25 mg and placebo once daily, each for 20 days, in random order. Study periods will be separated by a 2-6 weeks wash-out period. The primary efficacy outcome will be the amplitude of plasma glucose excursion (peak to nadir) during a mixed meal tolerance test. Results will be presented as paired-differences±SD plus 95% CIs with p values and hypothesis testing for primary and secondary outcomes according to intention-to-treat. Secondary outcomes include continuous glucose monitoring-based outcomes, further metabolic measures and safety. ETHICS AND DISSEMINATION The DEEP-EMPA trial (original protocol title: Randomized, double-blind, placebo-controlled crossover trialassessing the impact of the SGLT2 inhibitor empagliflozin onpostprandial hypoglycaemia after gastric bypass) was approved by the Bern Ethics Committee (ID 2021-01187) and Swissmedic (Ref. Number: 102663190) in October and November 2021, respectively. First results are expected in the first quarter of 2023 and will be disseminated via peer-reviewed publications and presented at national and international conferences. The acronym DEEP was derived from an overarching project title (DEciphering the Enigma of Postprandial Hyperinsulinaemic Hypoglycaemia after Bariatric Surgery), the term EMPA stands for the drug empagliflozin. TRIAL REGISTRATION NUMBER NCT05057819.
Collapse
Affiliation(s)
- Antonio Ferreira
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, University of Bern, Bern, Switzerland
| | | | - David Herzig
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, University of Bern, Bern, Switzerland
| | - Andreas Melmer
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, University of Bern, Bern, Switzerland
| | - Andreas P Vogt
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christos T Nakas
- Laboratory of Biometry, School of Agriculture, University of Thessaly, Volos, Greece
| | - Andrea Facchinetti
- Department of Information Engineering, University of Padova, Padova, Italy
| | - Chiara Dalla Man
- Department of Information Engineering, University of Padova, Padova, Italy
| | - Lia Bally
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, University of Bern, Bern, Switzerland
| |
Collapse
|
15
|
Salehi M, DeFronzo R, Gastaldelli A. Altered Insulin Clearance after Gastric Bypass and Sleeve Gastrectomy in the Fasting and Prandial Conditions. Int J Mol Sci 2022; 23:ijms23147667. [PMID: 35887007 PMCID: PMC9324232 DOI: 10.3390/ijms23147667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 07/01/2022] [Accepted: 07/03/2022] [Indexed: 11/17/2022] Open
Abstract
Background: The liver has the capacity to regulate glucose metabolism by altering the insulin clearance rate (ICR). The decreased fasting insulin concentrations and enhanced prandial hyperinsulinemia after Roux-en-Y gastric-bypass (GB) surgery and sleeve gastrectomy (SG) are well documented. Here, we investigated the effect of GB or SG on insulin kinetics in the fasting and fed states. Method: ICR was measured (i) during a mixed-meal test (MMT) in obese non-diabetic GB (n = 9) and SG (n = 7) subjects and (ii) during a MMT combined with a hyperinsulinemic hypoglycemic clamp in the same GB and SG subjects. Five BMI-matched and non-diabetic subjects served as age-matched non-operated controls (CN). Results: The enhanced ICR during the fasting state after GB and SC compared with CN (p < 0.05) was mainly attributed to augmented hepatic insulin clearance rather than non-liver organs. The dose-response slope of the total insulin extraction rate (InsExt) of exogenous insulin per circulatory insulin value was greater in the GB and SG subjects than in the CN subjects, despite the similar peripheral insulin sensitivity among the three groups. Compared to the SG or the CN subjects, the GB subjects had greater prandial insulin secretion (ISR), independent of glycemic levels. The larger post-meal ISR following GB compared with SG was associated with a greater InsExt until it reached a plateau, leading to a similar reduction in meal-induced ICR among the GB and SG subjects. Conclusions: GB and SG alter ICR in the presence or absence of meal stimulus. Further, altered ICR after bariatric surgery results from changes in hepatic insulin clearance and not from a change in peripheral insulin sensitivity.
Collapse
Affiliation(s)
- Marzieh Salehi
- Division of Diabetes, University of Texas Health at San Antonio, San Antonio, TX 78229, USA;
- South Texas Veteran Health Care System, Audie Murphy Hospital, San Antonio, TX 78229, USA
- Correspondence: (M.S.); (A.G.); Tel.: +1-(210)-450-8560 (M.S.)
| | - Ralph DeFronzo
- Division of Diabetes, University of Texas Health at San Antonio, San Antonio, TX 78229, USA;
| | - Amalia Gastaldelli
- Division of Diabetes, University of Texas Health at San Antonio, San Antonio, TX 78229, USA;
- Cardiometabolic Risk Unit, CNR Institute of Clinical Physiology, 56124 Pisa, Italy
- Correspondence: (M.S.); (A.G.); Tel.: +1-(210)-450-8560 (M.S.)
| |
Collapse
|
16
|
Salehi M, Gastaldelli A, DeFronzo R. Prandial hepatic glucose production during hypoglycemia is altered after gastric bypass surgery and sleeve gastrectomy. Metabolism 2022; 131:155199. [PMID: 35390439 DOI: 10.1016/j.metabol.2022.155199] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 03/22/2022] [Accepted: 03/30/2022] [Indexed: 12/12/2022]
Abstract
AIMS/HYPOTHESIS Roux-en Y gastric bypass surgery (GB) and sleeve gastrectomy (SG) alter prandial glucose metabolism, producing lower nadir glucose values and predisposing susceptible individuals to prandial hypoglycemia. The glycemic phenotype of GB or SG is associated with prandial hyperinsulinemia and hyperglucagonemia along with an increased influx of ingested glucose. Following insulin-induced hypoglycemia, glucagon is the most important stimulus for hepatic glucose production (HGP). It is unclear whether prandial hyperglucagonemia after GB or SG changes HGP under hyperinsulinemic hypoglycemia conditions. This study examined the hypothesis that prandial glucose production is reduced after GB and SG during hypoglycemia. METHODS Glucose kinetics and islet-cell and gut hormone secretion during hyperinsulinemic (120 mU.m-2.min-1) hypoglycemic clamp (~3.2 mM) were measured before and after mixed meal ingestion in 9 non-diabetic subjects with GB, 7 with SG, and 5 matched non-operated controls (CN). RESULTS Systemic appearance of ingested glucose was faster in GB compared to SG, and in SG compared to CN (p < 0.05). Subjects with GB and SG had greater plasma glucagon levels after eating (AUCGlucagon) compared to CN (p < 0.05). But prandial HGP response during insulin-induced hypoglycemia (AUCHGP) was smaller and shorter in duration in surgical groups (p < 0.05). In the absence of meal stimuli, however, glucose counterregulatory response to hypoglycemia was comparable among the 3 groups during hyperinsulinemic clamp. CONCLUSION After bariatric surgery, prandial glucose counterregulatory response to hypoglycemia is impaired. Considering post-meal hyperglucagonemia after GB or SG the blunted HGP response suggests a lower sensitivity of liver to glucagon that can predispose to hypoglycemia in this population.
Collapse
Affiliation(s)
- Marzieh Salehi
- Division of Diabetes, University of Texas at San Antonio, San Antonio, TX, United States; STVHCS, Audie Murphy Hospital, San Antonio, TX, United States.
| | - Amalia Gastaldelli
- Cardiometabolic Risk Unit, CNR Institute of Clinical Physiology, Pisa, Italy
| | - Ralph DeFronzo
- Division of Diabetes, University of Texas at San Antonio, San Antonio, TX, United States
| |
Collapse
|
17
|
Gao Z, Yang J, Liang Y, Yang S, Zhang T, Gong Z, Li M. Changes in Gastric Inhibitory Polypeptide (GIP) After Roux-en-Y Gastric Bypass in Obese Patients: a Meta-analysis. Obes Surg 2022; 32:2706-2716. [PMID: 35597875 DOI: 10.1007/s11695-022-05959-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 01/25/2022] [Accepted: 02/03/2022] [Indexed: 01/19/2023]
Abstract
This meta-analysis aimed to evaluate changes in GIP after RYGB in obese patients. We searched PubMed, EMBASE, and CENTRAL for relevant studies from database inception through July 2021. Articles were eligible for inclusion if they reported pre-operative and post-operative fasting GIP levels. We found fasting GIP levels had a decreasing tendency. The decrease in fasting glucose and postprandial GIP levels was also observed. Subgroup analysis indicated diabetic subjects tended to have a more obvious fasting GIP reduction compared to non-diabetic individuals. Meta-regression showed that the amount of weight loss (% total body weight), gastric pouch volume, alimentary limb length, and biliopancreatic limb length were not related to fasting GIP decrease. Fasting GIP levels decreased significantly after RYGB in obese people, especially in diabetic patients.
Collapse
Affiliation(s)
- Zhiguang Gao
- Department of Gastrointestinal Surgery, The affiliated Dongguan Shilong People's Hospital of Southern Medical University, Dongguan, 523320, China.
| | - Jingge Yang
- Department of Gastrointestinal Surgery, First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Yuzhi Liang
- Department of Medical Imaging, The affiliated Dongguan Shilong People's Hospital of Southern Medical University, Dongguan, 523320, China
| | - Sen Yang
- Guangdong Medical University, Zhanjiang, Guangdong Province, China
| | - Tao Zhang
- Department of Gastrointestinal Surgery, The affiliated Dongguan Shilong People's Hospital of Southern Medical University, Dongguan, 523320, China
| | - Zuyuan Gong
- Department of Gastrointestinal Surgery, The affiliated Dongguan Shilong People's Hospital of Southern Medical University, Dongguan, 523320, China
| | - Min Li
- Department of Gastrointestinal Surgery, The affiliated Dongguan Shilong People's Hospital of Southern Medical University, Dongguan, 523320, China
| |
Collapse
|
18
|
Schönenberger KA, Cossu L, Prendin F, Cappon G, Wu J, Fuchs KL, Mayer S, Herzig D, Facchinetti A, Bally L. Digital Solutions to Diagnose and Manage Postbariatric Hypoglycemia. Front Nutr 2022; 9:855223. [PMID: 35464035 PMCID: PMC9021863 DOI: 10.3389/fnut.2022.855223] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 03/14/2022] [Indexed: 11/29/2022] Open
Abstract
Postbariatric hypoglycemia (PBH) is an increasingly recognized late metabolic complication of bariatric surgery, characterized by low blood glucose levels 1–3 h after a meal, particularly if the meal contains rapid-acting carbohydrates. PBH can often be effectively managed through appropriate nutritional measures, which remain the cornerstone treatment today. However, their implementation in daily life continues to challenge both patients and health care providers. Emerging digital technologies may allow for more informed and improved decision-making through better access to relevant data to manage glucose levels in PBH. Examples include applications for automated food analysis from meal images, digital receipts of purchased food items or integrated platforms allowing the connection of continuously measured glucose with food and other health-related data. The resulting multi-dimensional data can be processed with artificial intelligence systems to develop prediction algorithms and decision support systems with the aim of improving glucose control, safety, and quality of life of PBH patients. Digital innovations, however, face trade-offs between user burden vs. amount and quality of data. Further challenges to their development are regulatory non-compliance regarding data ownership of the platforms acquiring the required data, as well as user privacy concerns and compliance with regulatory requirements. Through navigating these trade-offs, digital solutions could significantly contribute to improving the management of PBH.
Collapse
Affiliation(s)
- Katja A. Schönenberger
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| | - Luca Cossu
- Department of Information Engineering, University of Padova, Padova, Italy
| | - Francesco Prendin
- Department of Information Engineering, University of Padova, Padova, Italy
| | - Giacomo Cappon
- Department of Information Engineering, University of Padova, Padova, Italy
| | - Jing Wu
- Institute of Computer Science, University of St. Gallen, St. Gallen, Switzerland
| | - Klaus L. Fuchs
- ETH AI Center, Swiss Federal Institute of Technology (ETH) Zurich, Zurich, Switzerland
- Technology Studies, School of Humanities and Social Sciences, University of St. Gallen, St. Gallen, Switzerland
| | - Simon Mayer
- Institute of Computer Science, University of St. Gallen, St. Gallen, Switzerland
| | - David Herzig
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andrea Facchinetti
- Department of Information Engineering, University of Padova, Padova, Italy
| | - Lia Bally
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- *Correspondence: Lia Bally
| |
Collapse
|
19
|
Liu Y, Sheng C, Feng W, Sun F, Zhang J, Chen Y, Su L, Liu J, Du L, Jia X, You H, Huang X, Wu S, Lin Z, Qu S. A multi-center study on glucometabolic response to bariatric surgery for different subtypes of obesity. Front Endocrinol (Lausanne) 2022; 13:989202. [PMID: 36407309 PMCID: PMC9669340 DOI: 10.3389/fendo.2022.989202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 10/21/2022] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES To assess the benefit of a bariatric surgery in four artificial intelligence-identified metabolic (AIM) subtypes of obesity with respect to the improvement of glucometabolism and the remission of diabetes and hyperinsulinemia. METHODS This multicenter retrospective study prospectively collected data from five hospitals in China from 2010 to 2021. At baseline 1008 patients who underwent a bariatric surgery were enrolled (median age 31 years; median BMI 38.1kg/m2; 57.40% women) and grouped into the four AIM subtypes. Baseline and follow-up data (506 and 359 patients at 3- and 12-month post-surgery) were collected for longitudinal effect analysis. RESULTS Out of the four AIM subgroups, hypometabolic obesity (LMO) group was characterized by decompensated insulin secretion and high incidence of diabetes (99.2%) pre-surgery. After surgery, 62.1% of LMO patients with diabetes achieved remission, lower than the other three subgroups. Still, the bariatric surgery significantly reduced their blood glucose (median HbA1c decreased by 27.2%). The hypermetabolic obesity-hyperinsulinemia (HMO-I) group was characterized by severe insulin resistance and high incidence of hyperinsulinemia (87.8%) pre-surgery, which had been greatly alleviated post-surgery. For both metabolic healthy obesity (MHO) and hypermetabolic obesity-hyperuricemia (HMO-U) groups who showed a relatively healthy glucometabolism pre-surgery, rate of glucometabolic comorbidities improved moderately post-surgery. CONCLUSION In terms of glucometabolism, the four AIM subtypes of patients benefited differently from a bariatric surgery, which significantly relieved hyperglycemia and hyperinsulinemia for the LMO and HMO-I patients, respectively. The AIM-based subtypes may help better inform clinical decisions on bariatric surgery and patient counseling pertaining to post-surgery outcomes.
Collapse
Affiliation(s)
- Yao Liu
- Department of Endocrinology and Metabolism, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Chunjun Sheng
- Department of Endocrinology and Metabolism, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Wenhuan Feng
- Department of Endocrinology, Drum Tower Hospital Affiliated to Nanjing University Medical School, Nanjing, China
| | - Fang Sun
- Department of Hypertension and Endocrinology, Daping Hospital, Army Medical University, Chongqing Institute of Hypertension, Chongqing, China
| | - Jingjing Zhang
- National Clinical Research Center for Metabolic Diseases, Metabolic Syndrome Research Center, Key Laboratory of Diabetes Immunology, Ministry of Education, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
- Department of Metabolism and Endocrinology, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Ying Chen
- Ministry of Education, Key Laboratory of Metabolism and Molecular Medicine, Department of Endocrinology and Metabolism, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Lili Su
- Department of Endocrinology and Metabolism, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jia Liu
- Department of Endocrinology and Metabolism, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Lei Du
- Department of Endocrinology and Metabolism, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xuyang Jia
- Department of Endocrinology and Metabolism, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Hui You
- Department of Endocrinology and Metabolism, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xiu Huang
- Department of Endocrinology and Metabolism, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Shandong Wu
- Department of Radiology, Department of Biomedical Informatics, Department of Bioengineering, Intelligent Systems Program, University of Pittsburgh, Pittsburgh, PA, United States
- Department of Biomedical Informatics, Intelligent Systems Program, University of Pittsburgh, Pittsburgh, PA, United States
- Department of Bioengineering, Intelligent Systems Program, University of Pittsburgh, Pittsburgh, PA, United States
| | - Ziwei Lin
- Department of Endocrinology and Metabolism, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
- *Correspondence: Ziwei Lin, ; Shen Qu,
| | - Shen Qu
- Department of Endocrinology and Metabolism, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
- *Correspondence: Ziwei Lin, ; Shen Qu,
| |
Collapse
|
20
|
Fischer LE, Wolfe BM, Fino N, Elman MR, Flum DR, Mitchell JE, Pomp A, Pories WJ, Purnell JQ, Patti ME. Postbariatric hypoglycemia: symptom patterns and associated risk factors in the Longitudinal Assessment of Bariatric Surgery study. Surg Obes Relat Dis 2021; 17:1787-1798. [PMID: 34294589 PMCID: PMC9944569 DOI: 10.1016/j.soard.2021.04.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 04/26/2021] [Accepted: 04/28/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND Postbariatric hypoglycemia (PBH) can be a devastating complication for which current therapies are often incompletely effective. More information is needed regarding frequency, incidence, and risk factors for PBH. OBJECTIVES To examine hypoglycemia symptoms following Roux-en-Y gastric bypass (RYGB) and laparoscopic adjustable gastric banding (LAGB) and baseline and in-study risk factors. SETTING Multicenter, at 10 US hospitals in 6 geographically diverse clinical centers. METHODS A prospective, longitudinal cohort study of adults undergoing RYGB or LAGB as part of clinical care between 2006 and 2009 were recruited and followed until January 31, 2015, with baseline and annual postoperative research assessments. We analyzed baseline prevalence and post-operative incidence and frequency of self-reported hypoglycemia symptoms as well as potential preoperative risk factors. RESULTS In all groups, postoperative prevalence of hypoglycemia symptoms was 38.5%. Symptom prevalence increased postoperatively from 2.8%-36.4% after RYGB in patients without preoperative diabetes (T2D), with similar patterns in prediabetes (4.9%-29.1%). Individuals with T2D had higher baseline hypoglycemia symptoms (28.9%), increasing after RYGB (57.9%). Hypoglycemia symptoms were lower after LAGB, with 39.1% reported hypoglycemia symptoms at only 1 postoperative visit with few (4.0%) having persistent symptoms at 6 or more annual visits. Timing of symptoms was not restricted to the postprandial state. Symptoms of severe hypoglycemia were reported in 2.6-3.6% after RYGB. The dominant risk factor for postoperative symptoms was preoperative symptoms; additionally, baseline selective serotonin (SSRI) and serotonin-norepinephrine (SNRI) reuptake inhibitor use was also associated with increased risk in multivariable analysis. Weight loss and regain were not related to hypoglycemia symptom reporting. CONCLUSION Hypoglycemia symptoms increase over time after RYGB, particularly in patients without diabetes. In a small percentage, symptoms can be persistent or severe and require hospitalization. Preoperative hypoglycemia symptoms and SSRI/SNRI use in RYGB patients without diabetes is associated with increased risk of symptoms.
Collapse
Affiliation(s)
- Laura E. Fischer
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma,Correspondence: Laura E. Fischer, M.D., M.S., F.A.C.S., Director, OU Metabolic and Bariatric Surgery Program, Assistant Professor, Department of Surgery, University of Oklahoma Health Sciences Center, 800 Stanton L Young Blvd, Ste 9000, Oklahoma City, OK 73104. (L.E. Fischer)
| | - Bruce M. Wolfe
- Departments of Medicine, Surgery, and the School of Public Health at Oregon Health & Science University, Portland, Oregon
| | - Nora Fino
- Departments of Medicine, Surgery, and the School of Public Health at Oregon Health & Science University, Portland, Oregon
| | - Miriam R. Elman
- Oregon Health and Science – Portland State University School of Public Health, Portland, Oregon
| | - David R. Flum
- Department of Surgery, University of Washington, Seattle, Washington
| | - James E. Mitchell
- Department of Psychiatry and Behavioral Science, University of North Dakota School of Medicine, Grand Forks, North Dakota
| | - Alfons Pomp
- Department of Surgery, University of Montreal, Montreal, Quebec, Canada
| | - Walter J. Pories
- Metabolic Surgery Research Group, East Carolina University, Greenville, North Carolina
| | - Jonathan Q. Purnell
- Departments of Medicine, Surgery, and the School of Public Health at Oregon Health & Science University, Portland, Oregon
| | - Mary-Elizabeth Patti
- Research Division, Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts
| | | |
Collapse
|
21
|
Almby KE, Katsogiannos P, Pereira MJ, Karlsson FA, Sundbom M, Wiklund U, Kamble PG, Eriksson JW. Time Course of Metabolic, Neuroendocrine, and Adipose Effects During 2 Years of Follow-up After Gastric Bypass in Patients With Type 2 Diabetes. J Clin Endocrinol Metab 2021; 106:e4049-e4061. [PMID: 34086911 PMCID: PMC8475218 DOI: 10.1210/clinem/dgab398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Roux-en-Y gastric bypass surgery (RYGB) markedly improves glycemia in patients with type 2 diabetes (T2D), but underlying mechanisms and changes over time are incompletely understood. OBJECTIVE Integrated assessment of neuroendocrine and metabolic changes over time in T2D patients undergoing RYGB. DESIGN AND SETTING Follow-up of single-center randomized study. PATIENTS Thirteen patients with obesity and T2D compared to 22 healthy subjects. INTERVENTIONS Blood chemistry, adipose biopsies, and heart rate variability were obtained before and 4, 24, and 104 weeks post-RYGB. RESULTS After RYGB, glucose-lowering drugs were discontinued and hemoglobin A1c fell from mean 55 to 41 mmol/mol by 104 weeks (P < 0.001). At 4 weeks, morning cortisol (P < 0.05) and adrenocorticotropin (P = 0.09) were reduced by 20%. Parasympathetic nerve activity (heart rate variability derived) increased at 4 weeks (P < 0.05) and peaked at 24 weeks (P < 0.01). C-reactive protein (CRP) and white blood cells were rapidly reduced (P < 0.01). At 104 weeks, basal and insulin-stimulated adipocyte glucose uptake increased by 3-fold vs baseline and expression of genes involved in glucose transport, fatty acid oxidation, and adipogenesis was upregulated (P < 0.01). Adipocyte volume was reduced by 4 weeks and more markedly at 104 weeks, by about 40% vs baseline (P < 0.01). CONCLUSIONS We propose this order of events: (1) rapid glucose lowering (days); (2) attenuated cortisol axis activity and inflammation and increased parasympathetic tone (weeks); and (3) body fat and weight loss, increased adipose glucose uptake, and whole-body insulin sensitivity (months-years; similar to healthy controls). Thus, neuroendocrine pathways can partly mediate early glycemic improvement after RYGB, and adipose factors may promote long-term insulin sensitivity and normoglycemia.
Collapse
Affiliation(s)
- Kristina E Almby
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | | | - Maria J Pereira
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | | | - Magnus Sundbom
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Urban Wiklund
- Department of Radiation Sciences, Umeå University, Umeå, Sweden
| | - Prasad G Kamble
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Jan W Eriksson
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
- Correspondence: Jan W Eriksson, MD, Department of Medical Sciences, Clinical Diabetes and Metabolism, Uppsala University, 751 85 Uppsala, Sweden.
| |
Collapse
|
22
|
Khoraki J, Salluzzo JL, Campos GM. Comment on: Defining clinically important hypoglycemia in Patients with postbariatric hypoglycemia. Surg Obes Relat Dis 2021; 17:1872-1873. [PMID: 34481726 DOI: 10.1016/j.soard.2021.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 08/04/2021] [Accepted: 08/05/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Jad Khoraki
- Department of Surgery, Division of Bariatric and Gastrointestinal Surgery, Virginia Commonwealth University, Richmond, Virginia
| | - Jennifer L Salluzzo
- Department of Surgery, Division of Bariatric and Gastrointestinal Surgery, Virginia Commonwealth University, Richmond, Virginia
| | - Guilherme M Campos
- Department of Surgery, Division of Bariatric and Gastrointestinal Surgery, Virginia Commonwealth University, Richmond, Virginia
| |
Collapse
|
23
|
Lee D, Dreyfuss JM, Sheehan A, Puleio A, Mulla CM, Patti ME. Glycemic Patterns Are Distinct in Post-Bariatric Hypoglycemia After Gastric Bypass (PBH-RYGB). J Clin Endocrinol Metab 2021; 106:2291-2303. [PMID: 33974064 PMCID: PMC8277212 DOI: 10.1210/clinem/dgab323] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Indexed: 12/12/2022]
Abstract
CONTEXT Severe hypoglycemia with neuroglycopenia, termed post-bariatric hypoglycemia (PBH). typically occurs postprandially, but it is also reported after activity or mid-nocturnally. OBJECTIVE To quantify glycemia, glycemic variability, and magnitude/duration of low sensor glucose (SG) values in patients with PBH after Roux-en-Y gastric bypass (PBH-RYGB). METHODS This retrospective analysis of data from an academic medical center included individuals with PBH-RYGB (n = 40), reactive hypoglycemia without gastrointestinal surgery (Non-Surg Hypo, n = 20), prediabetes (Pre-DM, n = 14), newly diagnosed T2D (n = 5), and healthy controls (HC, n = 38). Masked continuous glucose monitoring (Dexcom G4) was used to assess patterns over 24 hours, daytime (6 am-midnight) and nighttime (midnight-6 am). Prespecified measures included mean and median SG, variability, and percent time at thresholds of sensor glucose. RESULTS Mean and median SG were similar for PBH-RYGB and HC (mean: 99.8 ± 18.6 vs 96.9 ± 10.2 mg/dL; median: 93.0 ± 14.8 vs 94.5 ± 7.4 mg/dL). PBH-RYGB had a higher coefficient of variation (27.3 ± 6.8 vs 17.9 ± 2.4%, P < 0.0001) and range (154.5 ± 50.4 vs 112.0 ± 26.7 mg/dL, P < 0.0001). Nadir was lowest in PBH-RYGB (42.5 ± 3.7 vs HC 49.0 ± 11.9 mg/dL, P = 0.0046), with >2-fold greater time with SG < 70 mg/dL vs HC (7.7 ± 8.4 vs 3.2 ± 4.1%, P = 0.0013); these differences were greater at night (12.6 ± 16.9 vs 1.0 ± 1.5%, P < 0.0001). Non-Surg Hypo also had 4-fold greater time with SG < 70 at night vs HC (SG < 70: 4.0 ± 5.9% vs 1.0 ± 1.5%), but glycemic variability was not increased. CONCLUSION Patients with PBH-RYGB experience higher glycemic variability and frequency of SG < 70 compared to HC, especially at night. These data suggest that additional pathophysiologic mechanisms beyond prandial changes contribute to PBH.
Collapse
Affiliation(s)
- Daniel Lee
- Research Division, Joslin Diabetes Center, Boston 02215, MA, USA
- Morehouse School of Medicine, Atlanta 30310, GA, USA
| | - Jonathan M Dreyfuss
- Research Division, Joslin Diabetes Center, Boston 02215, MA, USA
- Harvard Medical School, Boston 02115, MA, USA
| | - Amanda Sheehan
- Research Division, Joslin Diabetes Center, Boston 02215, MA, USA
| | - Alexa Puleio
- Research Division, Joslin Diabetes Center, Boston 02215, MA, USA
| | - Christopher M Mulla
- Research Division, Joslin Diabetes Center, Boston 02215, MA, USA
- Harvard Medical School, Boston 02115, MA, USA
- Current Affiliation for C. M. Mulla: Landstuhl Regional Medical Center, Germany
| | - Mary Elizabeth Patti
- Research Division, Joslin Diabetes Center, Boston 02215, MA, USA
- Harvard Medical School, Boston 02115, MA, USA
- Correspondence: Mary Elizabeth Patti MD, Room 620, Joslin Diabetes Center, 1 Joslin Place, Boston MA 02215, USA.
| |
Collapse
|
24
|
Almby KE, Lundqvist MH, Abrahamsson N, Kvernby S, Fahlström M, Pereira MJ, Gingnell M, Karlsson FA, Fanni G, Sundbom M, Wiklund U, Haller S, Lubberink M, Wikström J, Eriksson JW. Effects of Gastric Bypass Surgery on the Brain: Simultaneous Assessment of Glucose Uptake, Blood Flow, Neural Activity, and Cognitive Function During Normo- and Hypoglycemia. Diabetes 2021; 70:1265-1277. [PMID: 33674408 PMCID: PMC8275889 DOI: 10.2337/db20-1172] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 02/25/2021] [Indexed: 12/15/2022]
Abstract
While Roux-en-Y gastric bypass (RYGB) surgery in obese individuals typically improves glycemic control and prevents diabetes, it also frequently causes asymptomatic hypoglycemia. Previous work showed attenuated counterregulatory responses following RYGB. The underlying mechanisms as well as the clinical consequences are unclear. In this study, 11 subjects without diabetes with severe obesity were investigated pre- and post-RYGB during hyperinsulinemic normo-hypoglycemic clamps. Assessments were made of hormones, cognitive function, cerebral blood flow by arterial spin labeling, brain glucose metabolism by 18F-fluorodeoxyglucose (FDG) positron emission tomography, and activation of brain networks by functional MRI. Post- versus presurgery, we found a general increase of cerebral blood flow but a decrease of total brain FDG uptake during normoglycemia. During hypoglycemia, there was a marked increase in total brain FDG uptake, and this was similar for post- and presurgery, whereas hypothalamic FDG uptake was reduced during hypoglycemia. During hypoglycemia, attenuated responses of counterregulatory hormones and improvements in cognitive function were seen postsurgery. In early hypoglycemia, there was increased activation post- versus presurgery of neural networks in brain regions implicated in glucose regulation, such as the thalamus and hypothalamus. The results suggest adaptive responses of the brain that contribute to lowering of glycemia following RYGB, and the underlying mechanisms should be further elucidated.
Collapse
Affiliation(s)
- Kristina E Almby
- Department of Medical Sciences, Clinical Diabetes and Metabolism, Uppsala University, Uppsala, Sweden
| | - Martin H Lundqvist
- Department of Medical Sciences, Clinical Diabetes and Metabolism, Uppsala University, Uppsala, Sweden
| | - Niclas Abrahamsson
- Department of Medical Sciences, Clinical Diabetes and Metabolism, Uppsala University, Uppsala, Sweden
| | - Sofia Kvernby
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Markus Fahlström
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Maria J Pereira
- Department of Medical Sciences, Clinical Diabetes and Metabolism, Uppsala University, Uppsala, Sweden
| | - Malin Gingnell
- Department of Neurosciences and Department of Psychology, Uppsala University, Uppsala, Sweden
| | - F Anders Karlsson
- Department of Medical Sciences, Clinical Diabetes and Metabolism, Uppsala University, Uppsala, Sweden
| | - Giovanni Fanni
- Department of Medical Sciences, Clinical Diabetes and Metabolism, Uppsala University, Uppsala, Sweden
| | - Magnus Sundbom
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Urban Wiklund
- Department of Radiation Sciences, Umeå University, Umeå, Sweden
| | - Sven Haller
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Mark Lubberink
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Johan Wikström
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Jan W Eriksson
- Department of Medical Sciences, Clinical Diabetes and Metabolism, Uppsala University, Uppsala, Sweden
| |
Collapse
|
25
|
Affiliation(s)
- Leticia E Sewaybricker
- Department of Medicine, UW Medicine Diabetes Institute, University of Washington, Seattle, WA
| | - Ellen A Schur
- Department of Medicine, UW Medicine Diabetes Institute, University of Washington, Seattle, WA
| |
Collapse
|
26
|
Fabricius TW, Verhulst CEM, Kristensen PL, Tack CJ, McCrimmon RJ, Heller S, Evans ML, Amiel SA, Pieber TR, de Galan BE, Pedersen-Bjergaard U. Hyperinsulinaemic-hypoglycaemic glucose clamps in human research: a systematic review of the literature. Diabetologia 2021; 64:727-736. [PMID: 33566134 PMCID: PMC7940281 DOI: 10.1007/s00125-020-05361-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 11/09/2020] [Indexed: 11/26/2022]
Abstract
AIMS/HYPOTHESIS The hyperinsulinaemic-hypoglycaemic glucose clamp technique has been developed and applied to assess effects of and responses to hypoglycaemia under standardised conditions. However, the degree to which the methodology of clamp studies is standardised is unclear. This systematic review examines how hyperinsulinaemic-hypoglycaemic clamps have been performed and elucidates potential important differences. METHODS A literature search in PubMed and EMBASE was conducted. Articles in English published between 1980 and 2018, involving adults with or without diabetes, were included. RESULTS A total of 383 articles were included. There was considerable variation in essential methodology of the hypoglycaemic clamp procedures, including the insulin dose used (49-fold difference between the lowest and the highest rate), the number of hypoglycaemic steps (range 1-6), the hypoglycaemic nadirs (range 2.0-4.3 mmol/l) and the duration (ranging from 5 to 660 min). Twenty-seven per cent of the articles reported whole blood glucose levels, most venous levels. In 70.8% of the studies, a dorsal hand vein was used for blood sampling, with some form of hand warming to arterialise venous blood in 78.8% of these. Key information was missing in 61.9% of the articles. CONCLUSIONS/INTERPRETATION Although the hyperinsulinaemic-hypoglycaemic clamp procedure is considered the gold standard to study experimental hypoglycaemia, a uniform standard with key elements on how to perform these experiments is lacking. Methodological differences should be considered when comparing results between hypoglycaemic clamp studies. PROSPERO REGISTRATION This systematic review is registered in PROSPERO (CRD42019120083).
Collapse
Affiliation(s)
- Therese W Fabricius
- Department of Endocrinology and Nephrology, Nordsjællands Hospital, Hillerød, Denmark.
| | - Clementine E M Verhulst
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands.
| | - Peter L Kristensen
- Department of Endocrinology and Nephrology, Nordsjællands Hospital, Hillerød, Denmark
| | - Cees J Tack
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Rory J McCrimmon
- Department of Internal Medicine, University of Dundee, Dundee, UK
| | - Simon Heller
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - Mark L Evans
- Wellcome Trust/MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Stephanie A Amiel
- Department of Diabetes, School of Life Course Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Thomas R Pieber
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Bastiaan E de Galan
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands
- Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Ulrik Pedersen-Bjergaard
- Department of Endocrinology and Nephrology, Nordsjællands Hospital, Hillerød, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
27
|
Lundqvist MH, Almby K, Wiklund U, Abrahamsson N, Kamble PG, Pereira MJ, Eriksson JW. Altered hormonal and autonomic nerve responses to hypo- and hyperglycaemia are found in overweight and insulin-resistant individuals and may contribute to the development of type 2 diabetes. Diabetologia 2021; 64:641-655. [PMID: 33241460 PMCID: PMC7864814 DOI: 10.1007/s00125-020-05332-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 10/01/2020] [Indexed: 12/27/2022]
Abstract
AIMS/HYPOTHESIS Results from animal models and some clinical work suggest a role for the central nervous system (CNS) in glucose regulation and type 2 diabetes pathogenesis by modulation of glucoregulatory hormones and the autonomic nervous system (ANS). The aim of this study was to characterise the neuroendocrine response to various glucose concentrations in overweight and insulin-resistant individuals compared with lean individuals. METHODS Overweight/obese (HI, n = 15, BMI ≥27.0 kg/m2) and lean (LO, n = 15, BMI <27.0 kg/m2) individuals without diabetes underwent hyperinsulinaemic euglycaemic-hypoglycaemic clamps and hyperglycaemic clamps on two separate occasions with measurements of hormones, Edinburgh Hypoglycaemic Symptom Scale (ESS) score and heart rate variability (HRV). Statistical methods included groupwise comparisons with Mann-Whitney U tests, multilinear regressions and linear mixed models between neuroendocrine responses and continuous metabolic variables. RESULTS During hypoglycaemic clamps, there was an elevated cortisol response in HI vs LO (median ΔAUC 12,383 vs 4793 nmol/l × min; p = 0.050) and a significantly elevated adrenocorticotropic hormone (ACTH) response in HI vs LO (median ΔAUC 437.3 vs 162.0 nmol/l × min; p = 0.021). When adjusting for clamp glucose levels, obesity (p = 0.033) and insulin resistance (p = 0.009) were associated with elevated glucagon levels. By contrast, parasympathetic activity was less suppressed in overweight individuals at the last stage of hypoglycaemia compared with euglycaemia (high-frequency power of HRV, p = 0.024). M value was the strongest predictor for the ACTH and PHF responses, independent of BMI and other variables. There was a BMI-independent association between the cortisol response and ESS score response (p = 0.024). During hyperglycaemic clamps, overweight individuals displayed less suppression of glucagon levels (median ΔAUC -63.4% vs -73.0%; p = 0.010) and more suppression of sympathetic relative to parasympathetic activity (low-frequency/high-frequency power, p = 0.011). CONCLUSIONS/INTERPRETATION This study supports the hypothesis that altered responses of insulin-antagonistic hormones and the ANS to glucose fluctuations occur in overweight and insulin-resistant individuals, and that these responses are probably partly mediated by the CNS. Their potential role in development of type 2 diabetes needs to be addressed in future research. Graphical abstract.
Collapse
Affiliation(s)
| | - Kristina Almby
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Urban Wiklund
- Department of Radiation Sciences, Biomedical Engineering, Umeå University, Umeå, Sweden
| | | | - Prasad G Kamble
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Maria J Pereira
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Jan W Eriksson
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden.
| |
Collapse
|
28
|
Differences in the effects of laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass on gut hormones: systematic and meta-analysis. Surg Obes Relat Dis 2021; 17:444-455. [DOI: 10.1016/j.soard.2020.10.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 09/18/2020] [Accepted: 10/14/2020] [Indexed: 12/12/2022]
|
29
|
Istfan NW, Lipartia M, Anderson WA, Hess DT, Apovian CM. Approach to the Patient: Management of the Post-Bariatric Surgery Patient With Weight Regain. J Clin Endocrinol Metab 2021; 106:251-263. [PMID: 33119080 PMCID: PMC7765654 DOI: 10.1210/clinem/dgaa702] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 09/28/2020] [Indexed: 12/12/2022]
Abstract
CONTEXT Weight regain (WR) after bariatric surgery is emerging as a common clinical problem due to the increase in the number of procedures performed. Early interventions are necessary to curtail the potential recurrence of comorbid conditions. However, it is often difficult to recognize WR early enough to introduce mitigating measures because there are no current guidelines for timely diagnosis and assessment of the severity of this condition. OBJECTIVE We present a practical approach for the early recognition of WR, based on 11-year follow-up data from our multiethnic bariatric surgery patient population. METHODS We classify WR according to the rate of increase in weight relative to nadir weight, normalized per 30-day interval. We also review pertinent literature about the etiologic factors contributing to WR after bariatric surgery. RESULTS According to our algorithm, mild, moderate, and rapid WR are defined as weight increases of 0.2% to <0.5%, 0.5% to 1.0%, and more than 1.0% of nadir weight per 30 days, respectively. Treatment options, including dietary counseling, use of antiobesity medication, and consideration of surgical revision, are described. A case is presented to illustrate the utility of timely identification of WR and the importance of collaboration between bariatric surgeons, obesity medicine specialists, and dietitians. CONCLUSION Our approach emphasizes the importance of regular long-term follow-up for all bariatric surgery patients.
Collapse
Affiliation(s)
- Nawfal W Istfan
- Section of Endocrinology, Diabetes, Nutrition, and Weight Management, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Marine Lipartia
- Section of Endocrinology, Diabetes, Nutrition, and Weight Management, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Wendy A Anderson
- Section of Minimally Invasive Surgery, Department of Surgery, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Donald T Hess
- Section of Minimally Invasive Surgery, Department of Surgery, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Caroline M Apovian
- Section of Endocrinology, Diabetes, Nutrition, and Weight Management, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
- Correspondence and Reprint Requests: Caroline M. Apovian, MD, Boston Medical Center, 720 Harrison Ave, Ste 8100, Boston, MA 02118, USA. E-mail:
| |
Collapse
|
30
|
Barocrinology: The Endocrinology of Obesity from Bench to Bedside. Med Sci (Basel) 2020; 8:medsci8040051. [PMID: 33371340 PMCID: PMC7768467 DOI: 10.3390/medsci8040051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 12/03/2020] [Accepted: 12/04/2020] [Indexed: 12/11/2022] Open
Abstract
Obesity has reached pandemic proportions. Hormonal and metabolic imbalances are the key factors that lead to obesity. South Asian populations have a unique phenotype, peculiar dietary practices, and a high prevalence of consanguinity. Moreover, many lower middle-income countries lack appropriate resources, super-specialists, and affordability to manage this complex disorder. Of late, there has been a substantial increase in both obesity and diabesity in India. Thus, many more patients are being managed by different types of bariatric procedures today than ever before. These patients have many types of endocrine and metabolic disturbances before and after bariatric surgery. Therefore, these patients should be managed by experts who have knowledge of both bariatric surgery and endocrinology. The authors propose “Barocrinology”, a novel terminology in medical literature, to comprehensively describe the field of obesity medicine highlighting the role of knowing endocrine physiology for understating its evolution, insights into its complications and appreciating the changes in the hormonal milieu following weight loss therapies including bariatric surgery. Barocrinology, coined as a portmanteau of “baro” (weight) and endocrinology, focuses upon the endocrine and metabolic domains of weight physiology and pathology. This review summarizes the key pointers of bariatric management from an endocrine perspective.
Collapse
|
31
|
Mariën I, De Block C, Verrijken A, Van Dessel K, Peiffer F, Verhaegen A, Hubens G, Van Gaal L, Dirinck E. Features of oral glucose tolerance tests in patients after Roux-en-Y gastric bypass with and without hypoglycaemia symptoms in daily life: It's all about speed. Diabetes Obes Metab 2020; 22:2107-2119. [PMID: 32643861 DOI: 10.1111/dom.14130] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 06/26/2020] [Accepted: 06/28/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To evaluate the glucose and insulin profiles during an oral glucose tolerance test (OGTT) after Roux-en-Y gastric bypass (RYGB) in symptomatic and asymptomatic patients. RESEARCH DESIGN AND METHODS This retrospective study consisted of two groups that had undergone RYGB. The symptomatic (S) group (n = 27) had an OGTT at presentation, whereas the asymptomatic (A) group (n = 99) had an OGTT 1 year after RYGB. Each group was subdivided into two groups, namely, those with glycaemia <54 mg/dL (S1/A1) and those with glycaemia >54 mg/dL (S2/A2) during OGTT. Most of the patients underwent OGTT preoperatively. RESULTS Preoperatively, the glucose and insulin levels, as well as the speed of increase and decrease, were similar in all groups. Postoperatively, the minimum glucose levels during the OGTT did not differ between the symptomatic and asymptomatic groups (55 ± 19 vs. 54 ± 17 mg/dL) or between the S1 and A1 subgroups (39 ± 7 vs. 43 ± 8 mg/dL). The peak glucose values were higher in the symptomatic versus the asymptomatic group (236 ± 52 vs. 189 ± 43 mg/dL; P <0.05) and in the S1 and S2 versus the A1 and A2 subgroups. The speed of glucose increase and decline was significantly higher in the symptomatic group versus the asymptomatic group, with the speed of glucose decline being the highest in the S1 subgroup. CONCLUSION Assessing hypoglycaemia after a gastric bypass remains challenging. Our study suggests that the main difference in glucose dynamics between symptomatic and asymptomatic patients might be the speed of glucose and insulin increase and decline during OGTT rather than the absolute values obtained.
Collapse
Affiliation(s)
- Ilke Mariën
- Department of Endocrinology, Diabetology and Metabolism, Antwerp University Hospital, Antwerp, Belgium
| | - Christophe De Block
- Department of Endocrinology, Diabetology and Metabolism, Antwerp University Hospital, Antwerp, Belgium
- Laboratory of Experimental Medicine and Pediatrics, Antwerp University, Antwerp, Belgium
| | - An Verrijken
- Department of Endocrinology, Diabetology and Metabolism, Antwerp University Hospital, Antwerp, Belgium
- Laboratory of Experimental Medicine and Pediatrics, Antwerp University, Antwerp, Belgium
| | - Kristof Van Dessel
- Department of Endocrinology, Diabetology and Metabolism, Antwerp University Hospital, Antwerp, Belgium
- Laboratory of Experimental Medicine and Pediatrics, Antwerp University, Antwerp, Belgium
| | - Frida Peiffer
- Department of Endocrinology, Diabetology and Metabolism, Antwerp University Hospital, Antwerp, Belgium
| | - Ann Verhaegen
- Department of Endocrinology, Diabetology and Metabolism, Antwerp University Hospital, Antwerp, Belgium
| | - Guy Hubens
- Department of Abdominal Surgery, Antwerp University Hospital, Antwerp, Belgium
| | - Luc Van Gaal
- Department of Endocrinology, Diabetology and Metabolism, Antwerp University Hospital, Antwerp, Belgium
- Laboratory of Experimental Medicine and Pediatrics, Antwerp University, Antwerp, Belgium
| | - Eveline Dirinck
- Department of Endocrinology, Diabetology and Metabolism, Antwerp University Hospital, Antwerp, Belgium
- Laboratory of Experimental Medicine and Pediatrics, Antwerp University, Antwerp, Belgium
| |
Collapse
|
32
|
de Heide LJM, van den Broek M, van Dijk G, Emous M, van Beek AP. Diminished Counterregulatory Responses to Meal-Induced Hypoglycemia 4 Years After RYGB. Obes Surg 2020; 31:597-602. [PMID: 33063157 DOI: 10.1007/s11695-020-05035-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 10/01/2020] [Accepted: 10/06/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE Post-bariatric hypoglycemia is a complication of bariatric surgery, especially Roux-en-Y gastric bypass (RYGB). The counterregulatory hormonal and sympathetic neural responses were measured during a previously reported meal test in which 48% had an almost asymptomatic hypoglycemic event. MATERIALS AND METHODS Forty-four randomly selected patients 4 years after RYGB. A liquid meal test (MMT) after overnight fasting. Based on the glucose nadir during the MMT, patients were divided in a hypo group (glucose < 3.3 mmol/L) and a non-hypo group (glucose ≥ 3.3 mmol/L). Cortisol, epinephrine, norepinephrine, blood pressure, and heart rate were measured up to 180 min after ingestion of the meal. Incremental areas under the curve (iAUC), peak, and delta hormone responses after the glucose nadir were calculated. Parameters were compared between the hypo and non-hypo groups. RESULTS A total of 21/44 (48%) had an almost asymptomatic hypoglycemic event. Cortisol and epinephrine responses in the hypo group were not increased compared to the non-hypo group, and there were no signs of increased sympathetic nerve activity. Peak and delta cortisol were lower in the hypo compared to the non-hypo group. Norepinephrine was higher in the hypo group especially in the time frame 60-120 and 120-180 min after start of the meal. CONCLUSION No increase in epinephrine and a lower cortisol response to hypoglycemia were observed compared to normoglycemia during a meal test in patients after RYGB. Norepinephrine levels were higher in the hypo group. These findings may suggest that possible recurrent hypoglycemia after RYGB results in blunting of counterregulatory responses indicative of hypoglycemia-induced autonomic failure. CLIN TRIAL REGISTER ID ISRCTN 11738149.
Collapse
Affiliation(s)
- Loek J M de Heide
- Center for Obesity North-Netherlands (CON), Medical Center Leeuwarden, H. Dunantweg 2, 8934 AD, Leeuwarden, The Netherlands.
| | - Merel van den Broek
- Center for Obesity North-Netherlands (CON), Medical Center Leeuwarden, H. Dunantweg 2, 8934 AD, Leeuwarden, The Netherlands
| | - Gertjan van Dijk
- GELIFES-Neurobiology, Department of Behavioral Neuroscience, University of Groningen, Groningen, The Netherlands
| | - Marloes Emous
- Center for Obesity North-Netherlands (CON), Medical Center Leeuwarden, H. Dunantweg 2, 8934 AD, Leeuwarden, The Netherlands
| | - André P van Beek
- Department of Endocrinology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| |
Collapse
|
33
|
Counterregulatory responses to postprandial hypoglycemia after Roux-en-Y gastric bypass. Surg Obes Relat Dis 2020; 17:55-63. [PMID: 33039341 DOI: 10.1016/j.soard.2020.08.037] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 08/25/2020] [Accepted: 08/30/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Postbariatric hypoglycemia (PBH) is a potentially serious complication after Roux-en-Y gastric bypass (RYGB), and impaired counterregulatory hormone responses have been suggested to contribute to the condition. OBJECTIVES We evaluated counterregulatory responses during postprandial hypoglycemia in individuals with PBH who underwent RYGB. SETTING University hospital. METHODS Eleven women with documented PBH who had RYGB underwent a baseline liquid mixed meal test (MMT) followed by 5 MMTs preceded by treatment with (1) acarbose 50 mg, (2) sitagliptin 100 mg, (3) verapamil 120 mg, (4) liraglutide 1.2 mg, and (5) pasireotide 300 μg. Blood was collected at fixed time intervals. Plasma and serum were analyzed for glucose, insulin, glucagon, epinephrine, norepinephrine, pancreatic polypeptide (PP), and cortisol. RESULTS During the baseline MMT, participants had nadir blood glucose concentrations of 3.3 ± .2 mmol/L. At the time of nadir glucose, there was a small but significant increase in plasma glucagon. Plasma epinephrine concentrations were not increased at nadir glucose but were significantly elevated by the end of the MMT. There were no changes in norepinephrine, PP, and cortisol concentrations in response to hypoglycemia. After treatment with sitagliptin, 8 individuals had glucose nadirs <3.2 mmol/L (versus 4 individuals at baseline), and significant increases in glucagon, PP, and cortisol responses were observed. CONCLUSIONS In response to postprandial hypoglycemia, individuals with PBH who underwent RYGB only had minor increases in counterregulatory hormones, while larger hormone responses occurred when glucose levels were lowered during treatment with sitagliptin. The glycemic threshold for counterregulatory activation could be altered in individuals with PBH, possibly explained by recurrent hypoglycemia.
Collapse
|
34
|
Abstract
Bariatric surgery (BS) is today the most effective therapy for inducing long-term weight loss and for reducing comorbidity burden and mortality in patients with severe obesity. On the other hand, BS may be associated to new clinical problems, complications and side effects, in particular in the nutritional domain. Therefore, the nutritional management of the bariatric patients requires specific nutritional skills. In this paper, a brief overview of the nutritional management of the bariatric patients will be provided from pre-operative to post-operative phase. Patients with severe obesity often display micronutrient deficiencies when compared to normal weight controls. Therefore, nutritional status should be checked in every patient and correction of deficiencies attempted before surgery. At present, evidences from randomized and retrospective studies do not support the hypothesis that pre-operative weight loss could improve weight loss after BS surgery, and the insurance-mandated policy of a preoperative weight loss as a pre-requisite for admission to surgery is not supported by medical evidence. On the contrary, some studies suggest that a modest weight loss of 5-10% in the immediate preoperative period could facilitate surgery and reduce the risk of complications. Very low calories diet (VLCD) and very low calories ketogenic diets (VLCKD) are the most frequently used methods for the induction of a pre-operative weight loss today. After surgery, nutritional counselling is recommended in order to facilitate the adaptation of the eating habits to the new gastro-intestinal physiology. Nutritional deficits may arise according to the type of bariatric procedure and they should be prevented, diagnosed and eventually treated. Finally, specific nutritional problems, like dumping syndrome and reactive hypoglycaemia, can occur and should be managed largely by nutritional manipulation. In conclusion, the nutritional management of the bariatric patients requires specific nutritional skills and the intervention of experienced nutritionists and dieticians.
Collapse
Affiliation(s)
- Silvia Bettini
- Luca Busetto Center for the Study and the Integrated Management of Obesity, Padova University Hospital, Padova, Italy
| | - Anna Belligoli
- Luca Busetto Center for the Study and the Integrated Management of Obesity, Padova University Hospital, Padova, Italy
| | - Roberto Fabris
- Luca Busetto Center for the Study and the Integrated Management of Obesity, Padova University Hospital, Padova, Italy
| | - Luca Busetto
- Luca Busetto Center for the Study and the Integrated Management of Obesity, Padova University Hospital, Padova, Italy.
- Clinica Medica 3, Azienda Ospedaliera di Padova, Via Giustiniani 2, Padova, 35128, Italy.
| |
Collapse
|
35
|
Zhou LY, Deng MQ, Xiao XH. Potential contribution of the gut microbiota to hypoglycemia after gastric bypass surgery. Chin Med J (Engl) 2020; 133:1834-1843. [PMID: 32649508 PMCID: PMC7470015 DOI: 10.1097/cm9.0000000000000932] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Indexed: 12/12/2022] Open
Abstract
Obesity has become a global health problem. Lifestyle modification and medical treatment only appear to yield short-term weight loss. Roux-en-Y gastric bypass (RYGB) is the most popular bariatric procedure, and it sustains weight reduction and results in the remission of obesity-associated comorbidities for obese individuals. However, patients who undergo this surgery may develop hypoglycemia. To date, the diagnosis is challenging and the prevalence of post-RYGB hypoglycemia (PRH) is unclear. RYGB alters the anatomy of the upper gastrointestinal tract and has a combined effect of caloric intake restriction and nutrient malabsorption. Nevertheless, the physiologic changes after RYGB are complex. Although hyperinsulinemia, incretin effects, dysfunction of β-cells and α-cells, and some other factors have been widely investigated and are reported to be possible mediators of PRH, the pathogenesis is still not completely understood. In light of the important role of the gut microbiome in metabolism, we hypothesized that the gut microbiome might also be a critical link between RYGB and hypoglycemia. In this review, we mainly highlight the current possible factors predisposing individuals to PRH, particularly related to the gut microbiota, which may yield significant insights into the intestinal regulation of glucose metabolic homeostasis and provide novel clues to improve the treatment of type 2 diabetes mellitus.
Collapse
Affiliation(s)
- Li-Yuan Zhou
- Key Laboratory of Endocrinology, Translational Medicine Center, Ministry of Health, Department of Endocrinology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | | | | |
Collapse
|
36
|
Mulla CM, Zavitsanou S, Laguna Sanz AJ, Pober D, Richardson L, Walcott P, Arora I, Newswanger B, Cummins MJ, Prestrelski SJ, Doyle FJ, Dassau E, Patti ME. A Randomized, Placebo-Controlled Double-Blind Trial of a Closed-Loop Glucagon System for Postbariatric Hypoglycemia. J Clin Endocrinol Metab 2020; 105:5623031. [PMID: 31714583 PMCID: PMC7174034 DOI: 10.1210/clinem/dgz197] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 11/08/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Postbariatric hypoglycemia (PBH) can threaten safety and reduce quality of life. Current therapies are incompletely effective. METHODS Patients with PBH were enrolled in a double-blind, placebo-controlled, crossover trial to evaluate a closed-loop glucose-responsive automated glucagon delivery system designed to reduce severe hypoglycemia. A hypoglycemia detection and mitigation algorithm was embedded in the artificial pancreas system connected to a continuous glucose monitor (CGM, Dexcom) driving a patch infusion pump (Insulet) filled with liquid investigational glucagon (Xeris) or placebo (vehicle). Sensor/plasma glucose responses to mixed meal were assessed during 2 study visits. The system delivered up to 2 doses of study drug (300/150 μg glucagon or equal-volume vehicle) if triggered by the algorithm. Rescue dextrose was given for plasma glucose <55 mg/dL or neuroglycopenia. RESULTS Twelve participants (11 females/1 male, age 52 ± 2, 8 ± 1 years postsurgery, mean ± SEM) completed all visits. Predictive hypoglycemia alerts prompted automated drug delivery postmeal, when sensor glucose was 114 ± 7 vs 121 ± 5 mg/dL (P = .39). Seven participants required rescue glucose after vehicle but not glucagon (P = .008). Five participants had severe hypoglycemia (<55 mg/dL) after vehicle but not glucagon (P = .03). Nadir plasma glucose was higher with glucagon vs vehicle (67 ± 3 vs 59 ± 2 mg/dL, P = .004). Plasma glucagon rose after glucagon delivery (1231 ± 187 vs 16 ± 1 pg/mL at 30 minutes, P = .001). No rebound hyperglycemia occurred. Transient infusion site discomfort was reported with both glucagon (n = 11/12) and vehicle (n = 10/12). No other adverse events were observed. CONCLUSION A CGM-guided closed-loop rescue system can detect imminent hypoglycemia and deliver glucagon, reducing severe hypoglycemia in PBH. CLINICAL TRIALS REGISTRATION NCT03255629.
Collapse
Affiliation(s)
| | - Stamatina Zavitsanou
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA
| | | | - David Pober
- Research Division, Joslin Diabetes Center, Boston, MA
| | | | | | - Ipsa Arora
- Research Division, Joslin Diabetes Center, Boston, MA
| | | | | | | | - Francis J Doyle
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA
| | - Eyal Dassau
- Research Division, Joslin Diabetes Center, Boston, MA
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA
- Correspondence and Reprint Requests: Mary-Elizabeth Patti, MD, 1 Joslin Place, Boston, MA 02215. E-mail: ; or Eyal Dassau, PhD, Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, 29 Oxford Street, Cambridge, MA, 02138. E-mail:
| | - Mary Elizabeth Patti
- Research Division, Joslin Diabetes Center, Boston, MA
- Correspondence and Reprint Requests: Mary-Elizabeth Patti, MD, 1 Joslin Place, Boston, MA 02215. E-mail: ; or Eyal Dassau, PhD, Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, 29 Oxford Street, Cambridge, MA, 02138. E-mail:
| |
Collapse
|
37
|
Alawami F, Al Hajjaj A. Post Prandial Hyperinsulnemic Hypoglycemia Thirteen Years after Gastric Bypass Surgery. ELECTRONIC JOURNAL OF GENERAL MEDICINE 2020. [DOI: 10.29333/ejgm/7619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
38
|
Sheehan A, Patti ME. Hypoglycemia After Upper Gastrointestinal Surgery: Clinical Approach to Assessment, Diagnosis, and Treatment. Diabetes Metab Syndr Obes 2020; 13:4469-4482. [PMID: 33239898 PMCID: PMC7682607 DOI: 10.2147/dmso.s233078] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 10/28/2020] [Indexed: 12/11/2022] Open
Abstract
CONTEXT Post-bariatric hypoglycemia (PBH) is an increasingly encountered complication of upper gastrointestinal surgery; the prevalence of this condition is anticipated to rise given yearly increases in bariatric surgical procedures. While PBH is incompletely understood, there is a growing body of research describing the associated factors, mechanisms, and treatment approaches for this condition. EVIDENCE ACQUISITION Data are integrated and summarized from studies of individuals affected by PBH and hypoglycemia following upper gastrointestinal surgery obtained from PubMed searches (1990-2020). EVIDENCE SYNTHESIS Information addressing etiology, incidence/prevalence, clinical characteristics, assessment, and treatment were reviewed and synthesized for the practicing physician. Literature reports were supplemented by clinical experience as indicated, when published data were not available. CONCLUSION PBH can be life-altering and severe for a subset of individuals. Given the chronic nature of this condition, and sequelae of both acute and recurrent episodes, increasing provider awareness of both the condition and associated risk factors is critical for assessment, prompt diagnosis, treatment, and preoperative identification of individuals at risk.
Collapse
Affiliation(s)
- Amanda Sheehan
- Research Division, Joslin Diabetes Center, Boston, MA, USA
| | - Mary Elizabeth Patti
- Research Division, Joslin Diabetes Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Correspondence: Mary Elizabeth Patti Research Division, Joslin Diabetes Center, 1 Joslin Place, Boston, MA02215, USATel +1 617-309-1966Fax +1 617-309-2593 Email
| |
Collapse
|
39
|
Abstract
PURPOSE OF REVIEW New more stable formulations of glucagon have recently become available, and these provide an opportunity to expand the clinical roles of this hormone in the prevention and management of insulin-induced hypoglycemia. This is applicable in type 1 diabetes, hyperinsulinism, and alimentary hypoglycemia. The aim of this review is to describe these new formulations of glucagon and to provide an overview of current and future therapeutic opportunities that these may provide. RECENT FINDINGS Four main categories of glucagon formulation have been studied: intranasal glucagon, biochaperone glucagon, dasiglucagon, and non-aqueous soluble glucagon. All four have demonstrated similar glycemic responses to standard glucagon formulations when administered during hypoglycemia. In addition, potential roles of these formulations in the management of congenital hyperinsulinism, alimentary hypoglycemia, and exercise-induced hypoglycemia in type 1 diabetes have been described. As our experience with newer glucagon preparations increases, the role of glucagon is likely to expand beyond the emergency use that this medication has been limited to in the past. The innovations described in this review likely represent early examples of a pending large repertoire of indications for stable glucagon.
Collapse
Affiliation(s)
- Colin P Hawkes
- Division of Endocrinology and Diabetes, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Diva D De Leon
- Division of Endocrinology and Diabetes, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Institute for Diabetes, Obesity & Metabolism, Perelman School of Medicine, University of Pennsylvania, 12-134 Smilow Center for Translational Research, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Michael R Rickels
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Institute for Diabetes, Obesity & Metabolism, Perelman School of Medicine, University of Pennsylvania, 12-134 Smilow Center for Translational Research, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA.
- Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
| |
Collapse
|
40
|
Kandel D, Bojsen-Møller KN, Svane MS, Samkani A, Astrup A, Holst JJ, Madsbad S, Krarup T. Mechanisms of action of a carbohydrate-reduced, high-protein diet in reducing the risk of postprandial hypoglycemia after Roux-en-Y gastric bypass surgery. Am J Clin Nutr 2019; 110:296-304. [PMID: 30624666 DOI: 10.1093/ajcn/nqy310] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 10/11/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Postprandial hypoglycemia is a risk after Roux-en-Y gastric bypass (RYGB). OBJECTIVES We speculated that a carbohydrate-reduced, high-protein (CRHP) diet might reduce the risk of hypoglycemia and therefore compared the acute effects of a conventionally recommended (CR) diet and CRHP diet [55/30 energy percent (E%) carbohydrate and 15/30 E% protein, respectively] in RYGB patients. METHODS Ten individuals (2 males, 8 females, mean ± SD age 47 ± 7 y; stable body mass index 31 ± 6 kg/m2; 6 ± 3 y post-RYGB) with recurrent postprandial hypoglycemia documented by plasma glucose (PG) ≤3.4 mmol/L were examined on 2 d with isoenergetic CRHP or CR diets comprising a breakfast and subsequent lunch meal. RESULTS Peak PG was significantly reduced on the CRHP diet after breakfast and lunch by 11% and 31% compared with the CR diet. Nadir PG increased significantly on CRHP (by 13% and 9%). Insulin secretion was reduced, and glucagon secretion increased on the CRHP diet after both meals. Glucagon-like peptide 1 and glucose-dependent insulinotropic polypeptide secretion were lower after lunch but unaltered after breakfast on CRHP; β-cell function and insulin clearance were unchanged. CONCLUSIONS The CRHP diet lowered glucose excursions and reduced insulin secretion and incretin hormone responses, but enhanced glucagon responses compared with the CR diet. Taken together, the results may explain the decreased glucose variability and lower risk of postprandial hypoglycemia. This study was registered at clinicaltrials.gov as NCT02665715.
Collapse
Affiliation(s)
- Daniel Kandel
- Department of Endocrinology, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark
- Department of Endocrinology, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| | | | - Maria Saur Svane
- Department of Endocrinology, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark
| | - Amirsalar Samkani
- Department of Endocrinology, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| | - Arne Astrup
- Department of Nutrition, Exercise and Sports
| | - Jens J Holst
- Endocrinology Research Section, Department of Biomedical Sciences
- Section for Translational Physiology, Center for Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark
| | - Sten Madsbad
- Department of Endocrinology, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark
| | - Thure Krarup
- Department of Endocrinology, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| |
Collapse
|
41
|
Honka H, Salehi M. Postprandial hypoglycemia after gastric bypass surgery: from pathogenesis to diagnosis and treatment. Curr Opin Clin Nutr Metab Care 2019; 22:295-302. [PMID: 31082828 PMCID: PMC6598692 DOI: 10.1097/mco.0000000000000574] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
PURPOSE OF REVIEW The Roux-en-Y gastric bypass surgery (RYGB) improves glucose control in majority of patients with type 2 diabetes. However, a minority group of individuals develop a life-threatening complication of hyperinsulinemic hypoglycemia. The goal of this review is to identify underlying mechanisms by which RYGB cause hypoglycemia and describe pathogenesis-driven strategies to diagnose and treat this condition. RECENT FINDINGS Gastric bypass leads to higher and earlier peak levels of glucose and lower nadir glucose after eating along with larger insulin and glucagon-like peptide 1 (GLP-1) secretion, resetting the balance between glucose appearance and clearance after this procedure. These weight-loss independent glycemic effects of RYGB have been attributed to changes in ingested glucose appearance as a result of rapid nutrient emptying from stomach pouch to the intestine and increased glucose clearance as a result of prandial hyperinsulinemia. The exaggerated effect of RYGB on postmeal glucose metabolism is a syndrome of postprandial hyperinsulinemic hypoglycemia manifesting in a group of individuals several years after this surgery. Affected patients have larger systemic appearance of ingested glucose and greater postmeal secretion of insulin and GLP-1 compared to those with history of RYGB without symptomatic hypoglycemia. Current evidence supporting a multifactorial model of glucose dysregulation among patients with hypoglycemia will be highlighted in this review. SUMMARY Hypoglycemia after RYGB is a life-threatening condition and likely represents the extreme glycemic phenotype of this procedure. Diagnosis is challenging and treatment options are limited.
Collapse
Affiliation(s)
- Henri Honka
- Division of Diabetes, Department of Medicine, University of Texas Health Science Center
| | - Marzieh Salehi
- Division of Diabetes, Department of Medicine, University of Texas Health Science Center
- Bartter Research Unit, Audie Murphy Hospital, STVHCS, San Antonio, Texas, USA
| |
Collapse
|
42
|
Justinussen T, Madsbad S, Holst JJ, Bojsen-Møller KN. Pros and cons of Roux en-Y gastric bypass surgery in obese patients with type 2 diabetes. Expert Rev Endocrinol Metab 2019; 14:243-257. [PMID: 31215828 DOI: 10.1080/17446651.2019.1628639] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 06/04/2019] [Indexed: 02/06/2023]
Abstract
INTRODUCTION The worldwide prevalence of obesity and type 2 diabetes (T2D) constitutes an epidemic that is a threat to public health. Bariatric surgery, including Roux en-Y gastric bypass (RYGB), is currently the most effective treatment to induce long-term weight loss and remission of co-morbid conditions. Surgery, however, comes with an added risk of complications, highlighting the need to understand the comparative effectiveness and risks of surgical versus conventional approaches to the treatment of obesity and T2D. AREAS COVERED Positive and negative outcomes of RYGB surgery in patients with T2D are assessed, with a primary focus on RYGB surgery versus standard non-surgical treatment of obese patients with T2D in randomized clinical trials or high-quality observational cohorts. Searches were conducted in the PubMed database up to 11 April 2019 for relevant studies. EXPERT OPINION High-level evidence reveals that RYGB ameliorates the clinical manifestations of T2D to a significantly higher degree than medical therapy. Postoperative incidence of beneficial effects and complications, however, differ across subgroups of patients with different preoperative characteristics. Key knowledge gaps, particularly on long-term complications, microvascular- and macrovascular events, and mortality should be addressed, so treatment with RYGB can be applied in an individualized approach to maximize benefits and minimize complications.
Collapse
Affiliation(s)
- Tummas Justinussen
- a Department of Endocrinology , Copenhagen University Hospital Hvidovre , Hvidovre , Denmark
- b Novo Nordisk Foundation Centre for Basic Metabolic Research , University of Copenhagen , Copenhagen , Denmark
| | - Sten Madsbad
- a Department of Endocrinology , Copenhagen University Hospital Hvidovre , Hvidovre , Denmark
- b Novo Nordisk Foundation Centre for Basic Metabolic Research , University of Copenhagen , Copenhagen , Denmark
| | - Jens Juul Holst
- b Novo Nordisk Foundation Centre for Basic Metabolic Research , University of Copenhagen , Copenhagen , Denmark
- c Department of Biomedical Sciences, Faculty of Health , University of Copenhagen , Copenhagen , Denmark
| | - Kirstine Nyvold Bojsen-Møller
- a Department of Endocrinology , Copenhagen University Hospital Hvidovre , Hvidovre , Denmark
- b Novo Nordisk Foundation Centre for Basic Metabolic Research , University of Copenhagen , Copenhagen , Denmark
| |
Collapse
|
43
|
Emous M, van den Broek M, Wijma RB, de Heide LJM, van Dijk G, Laskewitz A, Totté E, Wolffenbuttel BHR, van Beek AP. Prevalence of hypoglycaemia in a random population after Roux-en-Y gastric bypass after a meal test. Endocr Connect 2019; 8:969-978. [PMID: 31234142 PMCID: PMC6612232 DOI: 10.1530/ec-19-0268] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Accepted: 06/12/2019] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Roux-en-Y gastric bypass (RYGB) is an effective way to induce sustainable weight loss and can be complicated by postprandial hyperinsulinaemic hypoglycaemia (PHH). To study the prevalence and the mechanisms behind the occurrence of hypoglycaemia after a mixed meal tolerance test (MMTT) in patients with primary RYGB. DESIGN This is a cross-sectional study of patients 4 years after primary RYGB. METHODS From a total population of 550 patients, a random sample of 44 patients completed the total test procedures. A standardized mixed meal was used as stimulus. Venous blood samples were collected at baseline, every 10 min during the first half hour and every 30 min until 210 min after the start. Symptoms were assessed by questionnaires. Hypoglycaemia is defined as a blood glucose level below 3.3 mmol/L. RESULTS The prevalence of postprandial hypoglycaemia was 48% and was asymptomatic in all patients. Development of hypoglycaemia was more frequent in patients with lower weight at surgery (P = 0.045), with higher weight loss after surgery (P = 0.011), and with higher insulin sensitivity calculated by the homeostasis model assessment indexes (HOMA2-IR, P = 0.014) and enhanced beta cell function (insulinogenic index at 20 min, P = 0.001). CONCLUSION In a randomly selected population 4 years after primary RYGB surgery, 48% of patients developed a hypoglycaemic event during an MMTT without symptoms, suggesting the presence of hypoglycaemia unawareness in these patients. The findings in this study suggest that the pathophysiology of PHH is multifactorial.
Collapse
Affiliation(s)
- Marloes Emous
- Centre for Obesity Northern-Netherlands (CON), Medical Centre Leeuwarden, Leeuwarden, The Netherlands
- Correspondence should be addressed to M Emous:
| | - Merel van den Broek
- Centre for Obesity Northern-Netherlands (CON), Medical Centre Leeuwarden, Leeuwarden, The Netherlands
| | - Ragnhild B Wijma
- Centre for Obesity Northern-Netherlands (CON), Medical Centre Leeuwarden, Leeuwarden, The Netherlands
| | - Loek J M de Heide
- Centre for Obesity Northern-Netherlands (CON), Medical Centre Leeuwarden, Leeuwarden, The Netherlands
| | - Gertjan van Dijk
- GELIFES-Neurobiology, Department of Behavioral Neuroscience, University of Groningen, Groningen, The Netherlands
| | - Anke Laskewitz
- Certe Laboratories, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Erik Totté
- Centre for Obesity Northern-Netherlands (CON), Medical Centre Leeuwarden, Leeuwarden, The Netherlands
| | - Bruce H R Wolffenbuttel
- Department of Endocrinology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - André P van Beek
- Centre for Obesity Northern-Netherlands (CON), Medical Centre Leeuwarden, Leeuwarden, The Netherlands
- Department of Endocrinology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| |
Collapse
|
44
|
Rickels MR, Robertson RP. Pancreatic Islet Transplantation in Humans: Recent Progress and Future Directions. Endocr Rev 2019; 40:631-668. [PMID: 30541144 PMCID: PMC6424003 DOI: 10.1210/er.2018-00154] [Citation(s) in RCA: 157] [Impact Index Per Article: 31.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 10/26/2018] [Indexed: 12/11/2022]
Abstract
Pancreatic islet transplantation has become an established approach to β-cell replacement therapy for the treatment of insulin-deficient diabetes. Recent progress in techniques for islet isolation, islet culture, and peritransplant management of the islet transplant recipient has resulted in substantial improvements in metabolic and safety outcomes for patients. For patients requiring total or subtotal pancreatectomy for benign disease of the pancreas, isolation of islets from the diseased pancreas with intrahepatic transplantation of autologous islets can prevent or ameliorate postsurgical diabetes, and for patients previously experiencing painful recurrent acute or chronic pancreatitis, quality of life is substantially improved. For patients with type 1 diabetes or insulin-deficient forms of pancreatogenic (type 3c) diabetes, isolation of islets from a deceased donor pancreas with intrahepatic transplantation of allogeneic islets can ameliorate problematic hypoglycemia, stabilize glycemic lability, and maintain on-target glycemic control, consequently with improved quality of life, and often without the requirement for insulin therapy. Because the metabolic benefits are dependent on the numbers of islets transplanted that survive engraftment, recipients of autoislets are limited to receive the number of islets isolated from their own pancreas, whereas recipients of alloislets may receive islets isolated from more than one donor pancreas. The development of alternative sources of islet cells for transplantation, whether from autologous, allogeneic, or xenogeneic tissues, is an active area of investigation that promises to expand access and indications for islet transplantation in the future treatment of diabetes.
Collapse
Affiliation(s)
- Michael R Rickels
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - R Paul Robertson
- Division of Metabolism, Endocrinology, and Nutrition, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
- Division of Endocrinology, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
- Pacific Northwest Diabetes Research Institute, Seattle, Washington
| |
Collapse
|
45
|
Capristo E, Panunzi S, De Gaetano A, Spuntarelli V, Bellantone R, Giustacchini P, Birkenfeld AL, Amiel S, Bornstein SR, Raffaelli M, Mingrone G. Response to Letter to the Editor: "Incidence of Hypoglycemia After Gastric Bypass vs Sleeve Gastrectomy: A Randomized Trial". J Clin Endocrinol Metab 2019; 104:732-733. [PMID: 30285256 DOI: 10.1210/jc.2018-01813] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 09/28/2018] [Indexed: 11/19/2022]
Affiliation(s)
- Esmeralda Capristo
- Department of Internal Medicine, Fondazione Policlinico Universitario A. Gemelli IRCSS, Rome, Italy
| | - Simona Panunzi
- CNR-Institute of Systems Analysis and Computer Science, BioMatLab, Rome, Italy
| | - Andrea De Gaetano
- CNR-Institute of Systems Analysis and Computer Science, BioMatLab, Rome, Italy
| | - Valerio Spuntarelli
- Department of Internal Medicine, Fondazione Policlinico Universitario A. Gemelli IRCSS, Rome, Italy
| | - Rocco Bellantone
- Department of General Surgery, Fondazione Policlinico Universitario A. Gemelli IRCSS, Rome, Italy
| | - Piero Giustacchini
- Department of General Surgery, Fondazione Policlinico Universitario A. Gemelli IRCSS, Rome, Italy
| | - Andreas L Birkenfeld
- Department of Medicine III, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
- Division of Diabetes and Nutritional Sciences, King's College London, London, United Kingdom
- Paul Langerhans Institute Dresden, Helmholtz Center Munich, University Hospital Dresden, a Member of the German Center for Diabetes Research, Dresden, Germany
| | - Stephanie Amiel
- Division of Diabetes and Nutritional Sciences, King's College London, London, United Kingdom
| | - Stefan R Bornstein
- Department of Medicine III, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
- Division of Diabetes and Nutritional Sciences, King's College London, London, United Kingdom
- Paul Langerhans Institute Dresden, Helmholtz Center Munich, University Hospital Dresden, a Member of the German Center for Diabetes Research, Dresden, Germany
| | - Marco Raffaelli
- Department of General Surgery, Fondazione Policlinico Universitario A. Gemelli IRCSS, Rome, Italy
| | - Geltrude Mingrone
- Department of Internal Medicine, Fondazione Policlinico Universitario A. Gemelli IRCSS, Rome, Italy
- Division of Diabetes and Nutritional Sciences, King's College London, London, United Kingdom
| |
Collapse
|
46
|
Laferrère B, Pattou F. Weight-Independent Mechanisms of Glucose Control After Roux-en-Y Gastric Bypass. Front Endocrinol (Lausanne) 2018; 9:530. [PMID: 30250454 PMCID: PMC6140402 DOI: 10.3389/fendo.2018.00530] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 08/22/2018] [Indexed: 12/14/2022] Open
Abstract
Roux-en-Y gastric bypass results in large and sustained weight loss and resolution of type 2 diabetes in 60% of cases at 1-2 years. In addition to calorie restriction and weight loss, various gastro-intestinal mediated mechanisms, independent of weight loss, also contribute to glucose control. The anatomical re-arrangement of the small intestine after gastric bypass results in accelerated nutrient transit, enhances the release of post-prandial gut hormones incretins and of insulin, alters the metabolism and the entero-hepatic cycle of bile acids, modifies intestinal glucose uptake and metabolism, and alters the composition and function of the microbiome. The amelioration of beta cell function after gastric bypass in individuals with type 2 diabetes requires enteric stimulation. However, beta cell function in response to intravenous glucose stimulus remains severely impaired, even in individuals in full clinical diabetes remission. The permanent impairment of the beta cell may explain diabetes relapse years after surgery.
Collapse
Affiliation(s)
- Blandine Laferrère
- Division of Endocrinology, New York Obesity Nutrition Research Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, United States
| | - François Pattou
- Translational Research on Diabetes, UMR 1190, Inserm, Université Lille, Lille, France
- Endocrine and Metabolic Surgery, CHU Lille, Lille, France
| |
Collapse
|
47
|
Salehi M, Vella A, McLaughlin T, Patti ME. Hypoglycemia After Gastric Bypass Surgery: Current Concepts and Controversies. J Clin Endocrinol Metab 2018; 103:2815-2826. [PMID: 30101281 PMCID: PMC6692713 DOI: 10.1210/jc.2018-00528] [Citation(s) in RCA: 123] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 05/01/2018] [Indexed: 12/12/2022]
Abstract
CONTEXT Hypoglycemia, occurring after bariatric and other forms of upper gastrointestinal surgery, is increasingly encountered by clinical endocrinologists. The true frequency of this condition remains uncertain, due, in part, to differences in the diagnostic criteria and in the affected populations, as well as relative lack of patient and physician awareness and understanding of this condition. Postbariatric hypoglycemia can be severe and disabling for some patients, with neuroglycopenia (altered cognition, seizures, and loss of consciousness) leading to falls, motor vehicle accidents, and job and income loss. Moreover, repeated episodes of hypoglycemia can result in hypoglycemia unawareness, further impairing safety and requiring the assistance of others to treat hypoglycemia. OBJECTIVE In this review, we summarize and integrate data from studies of patients affected by hypoglycemia after Roux-en-Y gastric bypass (RYGB) surgery, obtained from PubMed searches (1990 to 2017) and reference searches of relevant retrieved articles. Whereas hypoglycemia can also be observed after sleeve gastrectomy and fundoplication, this review is focused on post-RYGB, given the greater body of published clinical studies at present. OUTCOME MEASURES Data addressing specific aspects of diagnosis, pathophysiology, and treatment were reviewed by the authors; when not available, the authors have provided opinions based on clinical experience with this challenging condition. CONCLUSIONS Hypoglycemia, occurring after gastric bypass surgery, is challenging for patients and physicians alike. This review provides a systematic approach to diagnosis and treatment based on the underlying pathophysiology.
Collapse
Affiliation(s)
- Marzieh Salehi
- Diabetes Division, University of Texas Health at San Antonio, San Antonio, Texas
| | | | | | - Mary-Elizabeth Patti
- Research and Clinic Divisions, Joslin Diabetes Center and Harvard Medical School, Boston, Massachusetts
- Correspondence and Reprint Requests: Mary-Elizabeth Patti, MD, Research and Clinic Divisions, Joslin Diabetes Center and Harvard Medical School, 1 Joslin Place, Boston, Massachusetts 02215. E-mail:
| |
Collapse
|
48
|
Wexler DJ, Macias-Konstantopoulos W, Forcione DG, Xiong L, Cauley CE, Pierce KJ. Case 23-2018: A 36-Year-Old Man with Episodes of Confusion and Hypoglycemia. N Engl J Med 2018; 379:376-385. [PMID: 30044928 DOI: 10.1056/nejmcpc1802828] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Deborah J Wexler
- From the Departments of Medicine (D.J.W., D.G.F.), Emergency Medicine (W.M.-K.), Radiology (L.X.), Surgery (C.E.C.), and Pathology (K.J.P.), Massachusetts General Hospital, and the Departments of Medicine (D.J.W., D.G.F.), Emergency Medicine (W.M.-K.), Radiology (L.X.), Surgery (C.E.C.), and Pathology (K.J.P.), Harvard Medical School - both in Boston
| | - Wendy Macias-Konstantopoulos
- From the Departments of Medicine (D.J.W., D.G.F.), Emergency Medicine (W.M.-K.), Radiology (L.X.), Surgery (C.E.C.), and Pathology (K.J.P.), Massachusetts General Hospital, and the Departments of Medicine (D.J.W., D.G.F.), Emergency Medicine (W.M.-K.), Radiology (L.X.), Surgery (C.E.C.), and Pathology (K.J.P.), Harvard Medical School - both in Boston
| | - David G Forcione
- From the Departments of Medicine (D.J.W., D.G.F.), Emergency Medicine (W.M.-K.), Radiology (L.X.), Surgery (C.E.C.), and Pathology (K.J.P.), Massachusetts General Hospital, and the Departments of Medicine (D.J.W., D.G.F.), Emergency Medicine (W.M.-K.), Radiology (L.X.), Surgery (C.E.C.), and Pathology (K.J.P.), Harvard Medical School - both in Boston
| | - Lillian Xiong
- From the Departments of Medicine (D.J.W., D.G.F.), Emergency Medicine (W.M.-K.), Radiology (L.X.), Surgery (C.E.C.), and Pathology (K.J.P.), Massachusetts General Hospital, and the Departments of Medicine (D.J.W., D.G.F.), Emergency Medicine (W.M.-K.), Radiology (L.X.), Surgery (C.E.C.), and Pathology (K.J.P.), Harvard Medical School - both in Boston
| | - Christy E Cauley
- From the Departments of Medicine (D.J.W., D.G.F.), Emergency Medicine (W.M.-K.), Radiology (L.X.), Surgery (C.E.C.), and Pathology (K.J.P.), Massachusetts General Hospital, and the Departments of Medicine (D.J.W., D.G.F.), Emergency Medicine (W.M.-K.), Radiology (L.X.), Surgery (C.E.C.), and Pathology (K.J.P.), Harvard Medical School - both in Boston
| | - Kirsten J Pierce
- From the Departments of Medicine (D.J.W., D.G.F.), Emergency Medicine (W.M.-K.), Radiology (L.X.), Surgery (C.E.C.), and Pathology (K.J.P.), Massachusetts General Hospital, and the Departments of Medicine (D.J.W., D.G.F.), Emergency Medicine (W.M.-K.), Radiology (L.X.), Surgery (C.E.C.), and Pathology (K.J.P.), Harvard Medical School - both in Boston
| |
Collapse
|
49
|
Capristo E, Panunzi S, De Gaetano A, Spuntarelli V, Bellantone R, Giustacchini P, Birkenfeld AL, Amiel S, Bornstein SR, Raffaelli M, Mingrone G. Incidence of Hypoglycemia After Gastric Bypass vs Sleeve Gastrectomy: A Randomized Trial. J Clin Endocrinol Metab 2018; 103:2136-2146. [PMID: 29590421 DOI: 10.1210/jc.2017-01695] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 03/20/2018] [Indexed: 01/10/2023]
Abstract
CONTEXT We compared the incidence of hypoglycemia after Roux-en-Y gastric bypass (RYGB) vs sleeve gastrectomy (SG). DESIGN, SETTING, AND MAIN OUTCOME MEASURES Randomized, open-label trial conducted at the outpatient obesity clinic in a university hospital in Rome, Italy. The primary aim was the incidence of reactive hypoglycemia (<3.1 mmol/L after 75-g oral glucose load) at 1 year after surgery. Secondary aims were hypoglycemia under everyday life conditions, insulin sensitivity, insulin secretion, and lipid profile. RESULTS Of 175 eligible patients, 120 were randomized 1:1 to RYGB or SG; 117 (93%) completed the 12-month follow-up. Reactive hypoglycemia was detected in 14% and 29% of SG and RYGB patients (P = 0.079), respectively, with the effect of treatment in multivariate analysis significant at P = 0.018. Daily hypoglycemic episodes during continuous glucose monitoring did not differ between groups (P = 0.75). Four of 59 RYGB subjects (6.8%) had 1 to 3 hospitalizations for symptomatic hypoglycemia vs 0 in SG. The static β-cell glucose sensitivity index increased after both treatments (P < 0.001), but the dynamic β-cell glucose sensitivity index increased significantly in SG (P = 0.008) and decreased in RYGB (P = 0.004 for time × treatment interaction). Whole-body insulin sensitivity increased about 10-fold in both groups. CONCLUSIONS We show that reactive hypoglycemia is no less common after SG and is not a safer option than RYGB, but RYGB is associated with more severe hypoglycemic episodes. This is likely due to the lack of improvement of β-cell sensitivity to changes in circulating glucose after RYGB, which determines an inappropriately high insulin secretion.
Collapse
Affiliation(s)
| | - Simona Panunzi
- CNR-Institute of Systems Analysis and Computer Science, BioMatLab, Rome, Italy
| | - Andrea De Gaetano
- CNR-Institute of Systems Analysis and Computer Science, BioMatLab, Rome, Italy
| | | | | | | | - Andreas L Birkenfeld
- Department of Medicine III, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
- Diabetes and Nutritional Sciences, King's College London, London, United Kingdom
- Paul Langerhans Institute Dresden of the Helmholtz Center Munich at University Hospital Dresden, a member of the German Center for Diabetes Research, Dresden, Germany
| | - Stephanie Amiel
- Diabetes and Nutritional Sciences, King's College London, London, United Kingdom
| | - Stefan R Bornstein
- Department of Medicine III, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
- Diabetes and Nutritional Sciences, King's College London, London, United Kingdom
- Paul Langerhans Institute Dresden of the Helmholtz Center Munich at University Hospital Dresden, a member of the German Center for Diabetes Research, Dresden, Germany
| | - Marco Raffaelli
- Department of General Surgery, Catholic University, Rome, Italy
| | - Geltrude Mingrone
- Department of Internal Medicine, Catholic University, Rome, Italy
- Diabetes and Nutritional Sciences, King's College London, London, United Kingdom
| |
Collapse
|
50
|
Abstract
PURPOSE The purposes of this study are to identify the cumulative incidence of post-bariatric surgery hypoglycemia (PBSH), describe its symptomatology, and characterize treatment patterns at a large academic institution. MATERIALS AND METHODS All patients who underwent bariatric surgery at a single institution from 1985 to 2015 were identified using a clinical database, administrative billing data identified patients who were treated for hypoglycemia, and chart reviews were performed to make a diagnosis of PBSH based on Whipple's triad. PBSH cases were reviewed including patient diabetes history, symptomatology, and treatment measures. Univariate analyses were performed to identify correlations based on symptomatology, laboratory values, and treatments utilized. RESULTS Ninety (2.6%) of 3487 patients were diagnosed with PBSH with preoperative median age of 43 years, mean BMI of 50.0 kg/m2, and median glycated hemoglobin of 6.0%. Median time-to-first hypoglycemic event was 40.6 months. No factors were identified which predict symptom severity or resolution. The 24 (27%) patients who received pharmacotherapy to treat hypoglycemia were younger, had lower nadir blood glucose levels, and more frequent symptoms. Sixty-nine (79%) cases eventually resolved. CONCLUSIONS PBSH onset and severity are highly variable. Successful management of these patients can prove difficult and should include dietary therapy, the selective use of pharmacotherapy and surgery, and the use of a multidisciplinary team including bariatric surgeons and endocrinologists.
Collapse
|